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CLINICAL OBSERVATIONS

ON

FUNCTIONAL NERVOUS DISORDERS.

o-i'S

c?

BY

C. HiL]^DFIELD J0:NES,

3r.B. CAXTAB, ; F.E.C.P. LOND. : F.K.S. : PHVSIClAJf TO ST. MAKY'S HOSPITAL,

PHILADELPHIA:

he:n'ry c. lea.

1867.

PHILADELPHIA:
CCLLIKS, PKIKTER, '!05 JATXE STSEET

TO

SIR JAMES RANALD MARTIX, C.B., F.R.S.,

PHYSICIAN TO THE COUNCIL OF INDIA,

MEMBER OP THE ROYAL ASIATIC SOCIETY OP GREAT BRITAIN

AND IRELAND, ETC. ETC.,

®Ijts Maxk is glcbicattb,

AS A TRIBUTE OP RESPECT AND ADMIRATION DUE TO HIS MANLY
VIRTUES, HIS PROFESSIONAL ATTAINMENTS,

THE EMINENT SERVICES HE HAS RENDERED TO HIS COUNTRY,
BY HIS SINCERE AND OBLIGED FRIEND,

THE AUTHOR.

PREFACE.

This work professes to contain little more than a truthful record
of experience and an endeavour to view that experience in the light
of scientific research. Though I have cast it in the form of a trea-
tise on nervous disorders, I regard it, of course, as a mere and very
imperfect contribution to the literature of so great a subject. I have
only touched on those points which seemed to me to have most
bearing on practice, but have endeavored as far as possible to indi-
cate general principles both in pathology and treatment. I am not
without hope that the reviewing of a number of cognate affections
may be of advantage to the reader, as showing how close a family
resemblance prevails among them, and how the phenomena of one
often elucidate those of another disorder. I have necessarily been
led to set much value on the results of treatment as indications of
the essential nature of disease, in which I am supported by no less a
name than Gooch, and this will explain why 1 have recorded few cases
except those in which some definite conclusion can be drawn from
the actions of remedies. Having myself generally derived most
profit from the records of cases, I have used this method of illustra-
tion freely, and I trust not unprofitably. There is this value in
authentic histories of disease that they represent actual occurrences,
and are always available for any future inquirer as evidence of the
writer's views, which can hardly be said of abstract descriptions. I
do not think it so necessary, as some consider it, to be accurately
acquainted with the natural history of disease, for the reason that I
believe it impossible in most cases to ascertain it. The attempt
recently made by Flint to determine the duration of acute rheuma-
tism, no real treatment being adopted, gives in thirteen cases the
sufficiently wide variation of from twelve to fifty-six days. I believe
with most diseases except the exanthemata it would be nearly the
same. In fact I am more and more convinced that we ought not to

VI PREFACE.

think of diseases as uniform entities, but as very varying and incon-
stant pathological conditions.

The points which I would indicate as most worthy of attention
are the recognition of primary paresis of nervous centres, and its
distinction from reflex paralysis, the numerous illustrations of vaso-
motor nerve disorder, the theory of inhibitory action, the remarkable
afiinity between paralysis, spasm, anassthesia, and neuralgia, the
different quality of nervous disorder apparently of the same kind in
different instances, the intimate relation of neuralgia in most instances
to debility, and the importance of an accurate adjustment of reme-
dies to each individual case.

While I fully agree with my master, Arnold, on having an un-
feigned respect for all kinds of work, I yet think that we have clear
indications at the present day what kind of work is most needed,
and most likely to bear fruit. While duly estimating morbid ana-
tomy and minute physical diagnosis, I cannot but reiterate the wish
I have several years ago expressed, that we were more earnest in
inquiring into the working of our means of cure, and gaining a
more thorough mastery over them. Some united mode of action
might surely be devised, I care little about the particular plan, which
might in the course of years give us much more certain knowledge
about many things in therapeutics than we at present possess. What
is the real value of colchicum in gouty disease ? Is digitalis to be
specially relied on as a safe stimulant to a weak and failing heart ?
Have mercury and antimony a positive control over sthenic inflam-
matory action, or have they none ? Should the treatment of acute
disease differ materially in town and country folk ? What is the
real action of opium ? These and such questions as these I would
fain have answered as the profession could answer them if the means
at their disposal were effectually employed.

I must not conclude without expressing my thanks to many gen-
tlemen who have worked with me as clinical assistants during the
past thirteen years at St. Mary's, and whose help has often aided
me very greatly in studying the cases which have come before me.

49 Green Street,

Park Lane.

CONTENTS

Chapter I.

u

II.

l(

III.

l(

IV.

((

V.

11 ,

YI.

u

VII.

l(

VIII.

IC

IX.

ii

X.

a

XL

ii

XII.

u

XIII.

u

XIV.

n

XV.

a

XVI.

ii

XVII.

<(

XVIII.

u

XIX.

(I

XX.

a

XXI.

u

XXII.

ii

XXIII.

(C

XXIV.

li

XXV.

li

XXVI.

11

XXVII.

Introductory

General Pathology

Cerebral Anemia

Anemia op the Spinal Cord

Hyperemia of the Brain

Spinal Hyperemia

Cerebral Paresis

Spinal Paresis .

Cerebral Excitement

Delirium Tremens

Tetanus

Catalepsy

Epilepsy

Headache

Vertigo

Chorea

Paralysis Agitans

Spasmodic Affections

Sleeplessness

Facial Neuralgia

Facial Paralysis

Retinal Hyperesthesia

Throat Dysesthesia .

Lingual Neuralgia

Brachial Neuralgia .

Sciatica

Angina Pectoris

17

20

48

61

63

71

74

88

100

112

123

131

134

153

157

160

165

169

174

181

188

190

193

194

197

204

210

VUl

CONTENTS.

Chapter XXVIII.
" XXIX.

" XXX.

" XXXI.

XXXII
" XXXIII.
" XXXIV.
" XXXV.

" XXXVI.
" XXXVII.
" XXXVIII.

" XXXIX.

Appendix

VlNDExMIATIO

Eespiratory Neuroses
Myalgia . . . .
Abdominal Neuralgia
Neuroses of the Urinary Organs
Neuroses of the Lower Intestine
Uterine Neuroses
Cutaneous Neuroses .
Malarioid Disorder
Secretion Fluxes

Hysteria

Syphilitic and Rheumatic Nerve Af

fections .....
Remedies

PAGE

231
248
249
261
268
271
274
287
305
307

310
315

337

343

CLINICAL OBSERVATIONS

FUNCTIONAL NERVOUS DISORDERS.

CHAPTER I.

INTRODUCTORY.

Of all the parts which go to make up the wonderful whole of the
human body, there is none to which a deeper and mOre mysterious
'" interest is attached than to the nervous system. By this we think,
and move, and have our conscious being ; in this, if anywhere,
inhabits our " divinae particula aurse;" by this we are linked with
the outer world, and are capable of afiecting and being again affec-
ted by the persons and things around us. By this, our immaterial
acts upon and sways our material part ; and by the higher develop-
ment of this, and its capability for higher actions, man is especially
distinguished from the lower creation. All the passions and emo-
tions, all the intellectual efforts, all the perceptions and recollections^
operate through and on this system. If this be so, is it any wonder
that exhaustion should frequently befall this delicate and complex
machinery, or that its disorders should be amongst the most fre-
quent that our fallen nature is doomed to bear ? Even under
favourable circumstances, the nervous system must often be hardly
taxed : how much more, then, will this be the case when sorrow,
toil, and anxiety predominate in the lot assigned?

It is difficult to form a decided opinion on the matter; but there
seems, I think, reason to entertain the belief that failure of nervous
power is much more characteristic of disease of the present day, than
of that which prevailed thirty years ago. For this there may be
various causes : the greater confinement of large numbers of the
population within doors, and often in unhealthy rooms or workshops ;
the harder struggle to be maintained in the battle of life, the greater
amount of the commoda vitce — may all tend to increase the suscepti-
bility of the nervous system, and to impair its resisting power.
Further, in the two following instances we have, it seems to me,
considerable evidence of the altered character of morbid action, de-
pending, in all probability, on still more general causes than those
just mentioned. (1). Sir Ranald Martin informs me, that whereas
invalids returning from India used to take leave of their agues when
2

18 INTRODUCTORY.

they arrived in this country, this is no longer the case, relapses
being of frequent occurrence. Practitioners of long experience, also,
tell us that aguish disorder prevails of late years in places where
it was previously unknown, without there being any change in the
state of the soil to account for it. (2). There seems no question
that puerperal fever is a disease of very different character in differ-
ent epidemics. As Dr. Ferguson writes, "under this test," viz.,
of therapeutic action, " Gooch discovered that puerperal fevers
were many, requiring various modes of treatment." I believe this
statement cannot be denied ; and if not, it seems a legitimate infer-
ence that other diseases may vary also at different times. I may
add that my own experience certainly indicates that cholera has a
modifying influence on disease. I have not met with nearly so
many peculiar neuroses of depression the last few years, as I did
for three or four after the last epidemic. Dr. Prout gives testimony
to the same effect, v. p. 67.

However the exact truth may be, whether the type of disease is
altered or not, I hold it to be abundantly clear that the great
majority of disorders we have to treat at the present time show more
or less marked indications of failure of nervous power ; and I believe
it to be a matter of great practical moment to keep this steadily in
view. While, however, believing this, I also think that our current
pictures of disease are taken far too exclusively from the sick field
of large towns ; and I am much inclined to think that if our rural
brethren wrote as much as their urban fellows do, they would give
a somewhat different account.

The course I propose to pursue is, first, to consider the behaviour
of the nerves and nervous centres in certain well-marked simple
morbid states, and subsequently to notice the more important
features of several classic diseases, and of some other less commonly
recognized disorders. I do not intend to deal with the results of
manifest organic lesion, but to confine my attention chiefly to such
disorders as are termed functional. It seems to me a vain dispute,
whether in strict accuracy there are, or are not, any such disorders.
The probability is that there are not — that in all morbid action the
cells and the fibres of the organs undergo some molecular change
from their perfectly normal condition. It is, however, perfectly
certain that there are very grave disorders in which the most care-
ful scrutiny fails to detect any actual change, in which complete
recovery is perfectly possible, and in which the " juvantia" are such
as operate more in modifying the power of the organs than their
texture. To take an example : a man may have paralysis of some
muscle or group of muscles which yields to the use of strychnia or
galvanism. Now, these agents can scarcely be thought to act other-
wise than by exciting and increasing the vital power of the affected
nerve or nervous centre; or, to put it shortly, as nerve tonics.
Cod-liver oil, iron, and phosphorus might be given without effecting
the same beneficial change — at least, as speedily, because they are

I^^TRODUCTORY. 19

rather analeptics than tonics. They may improve the nutrition of
the nervous tissue, but they do not directly arouse it. Now,
between such a case of functional paralysis as we have supposed,
and paralysis from organic lesion, there is a wide interval. Strych-
nia and galvanism will, in all probability, make the latter worse ;
certainly, will not cure it. Something more is needed in this case
than to arouse defective nervous energy. Between the typical cases
which we have taken of functional and organic disease, there inter-
vene numerous instances of more or less mixed character. Inflam-
matory disease is from one point of view organic, from another
functional. It commences essentially as the latter, it ends as the
former.

The arrangement I shall adopt is merely topographical, but will,
I hope, be found practically convenient. Commencing with the
encephalon, including the cerebral hemispheres, mesocephale, cere-
bellum, and medulla oblongata, we shall proceed to the spinal cord,
and thence to the several nerves or nervous districts, which are
found by experience to be most prone to disorder. Under the term
cerebral hemispheres is comprised all the convoluted gray exterior
of the brain, with its basal ganglia, the corpora striata and thalami
optici, and the various longitudinal and transverse comni[^sural fibres.
The functions of these parts are eminently mental : they^minister to
conscious sensation, memory, reflection, judgment, and volition.
Their structure is essentially similar to that of other nervous centres,
but has this peculiarity — that the gray matter contains a very con-
siderable quantity of loose granular material, and is by no means
chiefly made up of nervous cells. This seems to have relation to
the rapid nutritional change required by the active function of the
tissue. The perfect cell indicates a greater degree of permanency,
and slower change than the nucleus with diffused granular material.
The very copious supply of blood sent to the hemispheres is also in
harmony with this view. The cerebellum is probably concerned in
regulating the motor nervous actions, and is, perhaps, the special
seat of the muscular sense. The mesocephale is connected with the
two chief nerves of special sense, and is, we know from experiment,
capable of producing general convulsions when directly irritated.
The medulla oblongata is the chief centre of the respiratory nervous
actions, and is capable of influencing very materially the cardiac
movements : with it are connected all the cranial nerves from the
sixth to the ninth. The spinal cord constitutes by its gray matter
an independent centre for the nerves which are implanted in it, but
is naturally associated by its longitudinal commissural fibres with
the superior nervous centres in sensation and volition. The cervi-
cal and upper dorsal regions of the cord constitute, according to
Bezold, a special motor centre to the heart, furnishing three-fourths
of its entire propulsive force. The sympathetic is partly an inde-
pendent system, partly an offset from the cerebro-spinal ; as, indeed,
its anatomy indicates.

20 GENERAL PATHOLOGY.

CHAPTER II.

GENERAL PATHOLOGY.

Before entering on the special study of disease, it seems desirable
to allude briefly to some well-established points in neuro-physiology
and pathology, and to discuss, in a general manner, some questions
which are as yet unsolved. The subjects thus elucidated will be
convenient for future reference.

(I.) It is certain that the nervous cords, whether motor or sensory,
in the whole of their course, from their origin to their peripheral
distribution, allow of no communication of the active state from one
fibre to another. A single point of the skin when touched is dis-
tinguished by the sensorium from the adjacent, the size of the district
thus represented in the brain varying inversely with the abundance
of nervous s\^ply ; and a single muscle can be put into action with-
out exciting others receiving nerves from the same trunk. It is
remarkable how the stimulus of the will can be limited to certain
groups of nerve-cells at some distance from each other without
affecting others in close proximity. We can call into action the
triceps extensor cubiti without moving any other muscle. Yet, the
filaments animating this nerve must come, in all probability, from
various points of the spinal cord between the fifth cervical and first
dorsal nerves; and the cells of these points alone are excited, while
others close by remain inactive.

(II.) While the above, which Romberg terras the law of isolated
conduction, holds in the peripheral tracts, we find another of a very
different kind to come into play in the nervous centres. In them
we have — (a.) What is termed excito-motory or reflex action, viz., an
impression from a centripetal nerve, producing an active state of a
motor through the intermedium of certain multipolar cells. Sensa-
tion almost invariably ensues at the same time, but is not an essential
part of the chain of actions. Volition is quite unconcerned in the
act, and is often quite incapable of controlling it. (b.) The impres-
sion arriving at the centre is communicated, not to a motor, but to
a sensory nerve-root, perhaps to several adjacent, or to another more
remote. In this way, sensations are produced which continue as
long as the original impression is maintained by its existing cause.
In certain states of great excitability of the nervous centres, the
range over which the primary stimulus may extend, especially in
the case where motor nerves are aff'ected, is very considerable. In
dealing with neuralgic disorders, this point, viz., the irradiation, as
it is called, of sensation, is of capital importance, and may often lead

GENERAL PATHOLOGY. 21

to the discovery of the cause of suffering, which would otherwise
have remained quite obscure.

Pflliger lays down the following laws: (1.) That when reflex
action occurs on one side, it is always on that where the sensitive
nerve has been excited ; and if it occurs on both sides, it is strongest
on the side stimulated. (2.) When reflex action occurs on both
sides from excitation of one, it affects parts symmetrically situated.
(3.) Reflex excitation in cerebral nerves extends from before back-
wards, in spinal nerves from behind forwards. (Vide Brit, cf- For.
Med.-Ghir. Rev., Jan. 1864, p. 9.)

(III.) The law of eccentric phenomena affirms that every sensation,
as it becomes perceptible to consciousness, is referred to the periphery
of a sensitive fibre, no matter at what part of the whole length of
the fibre the impression is made. This law is to a certain extent
true, but admits, as I shall point out subsequently, of numerous
exceptions.

(IV.) It seems to be well ascertained that an unfelt irritation
may give rise to very various morbid phenomena affecting both the
motor and sensory nervous organs. Dr. Brown-Sequard maintains
that various forms of insanity, of vertigo, epilepsy, of hallucinations
and illusions, and also extasis, catalepsy, hysteria, chorea, hydro-
phobia, tetanus, &c., may be due to irritations starting from a cen-
tripetal nerve, and frequently slightly felt, or unfelt, and that the
suppression of these irritations may promptly cure the patient.
Graves records a case (Vide Clin. Med.., p. 244) where an extremely
severe cough, which had resisted all treatment directed to relieve,
bronchitis, ceased at once on the expulsion of a mass of tapeworm
by a dose of turpentine. It does not appear that any symptoms
had existed in this case to announce the presence of the intestinal
parasite. Perhaps the following instance is still more proving,
inasmuch as the seat of the irritation was in a much more sensitive part.
A married lady had suffered for a considerable time from a spasmodic
pain in the womb, which ceased completely on the extraction of a
tooth that had not caused any material annoyance.

(V.) Attention has lately been directed by Pflliger and Lister to
certain nerve phenomena, which the former terms inhibitory [hem-
mungs), and supposes to belong to a certain set or system of nerve-
fibres whose sole function is to arrest or diminish action. Lister,
on the contrary, concludes, from his inquiries,^ " that one and the
same afferent nerve may, according as it is operating mildly or
energetically, either exalt or depress the functions of the nervous
centre on which it acts. It is, I believe (he says), upon this that
all inhibitory influence depends ; and I suspect that the principle
■will be found to admit of a very general application in physiology."
The following are instances of inhibitory action : The poles of a
galvanic apparatus being fixed to the spinous processes of the ninth

' Proceedings of the Royal Society, No. 32, p. 367.

22 GENERAL PATHOLOGY.

and twelfth dorsal vertebrse of a rabbit, currents were passed through
the spine (of course, affecting the cord), with the effect of inducing
'•complete relaxation and quiescence of the small intestines, which
had been previously in considerable movement, while the muscles
of the limbs were thrown into spasmodic action ; but on the dis-
continuance of the galvanism the previous intestinal motion re-
turned." Weaker currents were then passed, and markedly in-
creased the action of the intestines in every instance during the
first twenty-five minutes. In the next half-hour the increase of
action from the galvanism though still distinct, was less strongly
marked, and at the end of that period, with stronger currents, the
inhibitory influence was also found to be much less complete than
before, indicating that the parts of the nervous apparatus concerned
were in a less active condition, no doubt in consequence of exhaus-
tion. Increased movements of the intestine were produced by
direct irritation of the cord with a fine needle. It was very worthy
of remark, that violent struggling of the rabbit, when the intestines
were in pretty free movement, was followed by absolute and uni-
versal quiescence of those organs for several seconds. This showed
that an inhibitory action was capable of being produced naturally
as well as artificially. The recent observations of Hufschmidt and
Moleschott,^ as to the effect of mechanical irritation of the medulla
oblongata and spinal cord on the frequency of the pulse, accord
very much with those of Lister. They found^ that slight electric
irritation of the medulla oblongata augmented, while more powerful
.diminished the frequency of the heart's action, or even arrested it.
(2). Powerful mechanical irritation ofthe medulla oblongata diminished
the frequency of the heart's action. (3). Slight irritation of the
spinal cord increases, powerful irritation diminishes the frequency
of the heart's action. Weber and Bernard^ had long before demon-
strated the possibility of arresting or slowing the action of the heart
by galvanizing the medulla oblongata or the pneumogastric nerve.

In a paper on Inhibitory Influence^ I have endeavoured to show
that pathological phenomena are not infrecjuent which seem to be of
this nature. I modify, however, the statement of Mr. Lister, so far
as to believe that it is not the energetic operation of an afferent
nerve that causes inhibitory action, but its being injuriously affected
by some impression made upon it. The enfeebled state of the nerve
itself, or of the centre to which it proceeds, or the severity or
malignity of the impression, may give rise to the peculiar effect.
The following instances may be cited as fair examples : 0. J.," ast.
37, got a whitlow on the last phalanx of left thumb ; the lymphatics
were inflamed, and the axillary glands swollen ; the whole arm was

1 Moleschott's Untersuch, vol. viii. part 6, 1862. Syd. Soc. Year-book, 1863,
p. 17.

2 LecoDS snr le Systiime Nerveux. tome ii. p. 392.

3 British Medical .Journal, February 5, 1859.

* Medical Times and Gazette, Januaj'y 29, 1859.

GENERAL PATHOLOGY. 23

very painful. While the limb was in this state, one morning he
found that he saw double, and had a squint in the left eye. At the
Ophthalmic Hospital, it was found that the external rectus muscle
was completely paralyzed, and he had circuraorbital pain. It was
supposed that there was periosteal inflammation about the orbit, and
pot. iodid. was given ; the whitlow was poulticed, and the arm
fomented. After a month of this treatment, there was no improve-
ment of the eye, but the arm inflammation had quite subsided. A
piece of dead bone was now removed from the seat of the whitlow ;
soon after which the squint disappeared, as well as the pain in the
arm and about the orbit. The external rectus had quite recovered
its power. In this instance, pain in sensory nerves about the orbit
and paralysis of a single motor nerve were co-results of the morbid
impression conveyed from the diseased finger to the centre. Dr.
Watson refers to the production of amaurosis without visible change
in the eye, in consequence, apparently, of irritation of the dental
nerves, the blindness ceasing after the extraction of some teeth
which had grown irregularly.^ He quotes from Mr. Lawrence an
interesting case, in which the extraction of a carious tooth, with a
splinter of wood projecting from one of its fangs, procured the
restoration of the sight of the eye of the same side, which had been
entirely lost for thirteen months. In such cases, the paralysis of
the retina or of the optic tubercles may fairly be designated inhibi-
tory. Two cases of amaurosis and one of ptosis are recorded by Mr.
Hancock^ as cured by the removal of decayed or overcrowded teeth.
]Mr. Fleischmann^ gives a case in which an obstinate muco-purulent
discharge from the right nostril, which had resisted other treatments,
yielded to extraction of the right upper canine. Plucking the large
vibrissa at the entrance of the nostrils will, at least in some persons,
cause a notable secretion of mucus, evidently dependent on the pain
excited. Some while ago, I had a gentleman under my care with
acute rosacea of the face and head, and chronic corneitis, with
vascular development on the cornea. I applied on one occasion
some liq. plumbi diacet., diluted with an equal amount of water, to
the upper lids (everted), which I found very red. This caused ex-
cessive irritation ; the eyes became greatly congested, watered,
extremely, and were very painful ; while the skin of the face, the
nose especially, became of a deep red, and all the vessels of the
face much congested. There was extreme photophobia. It was
half an hour before the hypersemia began to subside. The irrita-
tion in this case evidently was reflected from the branches of the
first division of the fifth nerve supplying the lids, on to the vaso-
motor nerves of the arteries, supplying the skin of the face, which,
in consequence of the morbid impression, became dilated — not con-
tracted, as they normally should, according to the law of reflex

' Watson's Lectures, voL i. p. 336. 2 Lancet, January 22, 1859.

3 British Medical Journal, April 9, 1859.

24 GENERAL PATHOLOGY.

action. This was a marked example of inhibitory action. Dr.
Brinton informs me that he has long held and taught a view almost
identical with the above, under the name of "reflex relaxation."
The pathology of these cases is, no doubt, the same ; a nerve of
special sense, a musculo-motor or a vaso-motor being paralyzed
according to the direction which the irritation happens to take. To
the same class belong, I think, instances of paralysis produced by
exposure to cold and wet, though the paralysis often continues long
after the morbid impression has ceased. In Mr, Hancock's com-
munication, a case of lockjaw and of extreme wryneck are men-
tioned as having been cured by removal of dental irritation. This
shows that it depends very much on the condition of the nervous
centre which is affected, what the result of a nervous stimulus shall
be, whether paralyzing or exciting. So, in some persons opium
causes marked powerlessness (a degree of paralysis) ; in others it
tones and prevents fatigue.

The only objection which can be made, I conceive, to the above
evidence is, that in the instances cited the paralysis depended, not
on a direct morbid influence exerted on the tissue of the nervous
centrCjbutonansemiaof the part, producedby the reflection of the origi-
nal irritation on the vaso-motor nerves supplying its arteries. This
is what Dr. Brovvn-Sequard supposes to occur in reflex paralysis —
a form which appears to me to be similar to inhibitory. In reflex
paralysis, the loss of motor power appears to depend on an actually
existing irritation, with which it increases or diminishes, and with
the removal of which it ceases. This is evidently almost identical
with what we have described above. The only diff"erence is, that
in some instances of inhibitory action the paretic state of the centre
persists for an indefinite time after the cessation of the cause which
has morbidly aS'ected it. The grounds which lead me to believe
that Brown-Sequard's view is incorrect are — (1st). It is difficult to
suppose that a spasm of reflex origin should be limited to such a
very small extent of vessels as would be involved in some instances,
e g., palsy of one sixth nerve, ptosis of one eye. (2d). It is almost
impossible to believe that a contraction of vessels should be so per-
.sistent as the hypothesis requires. Can we suppose, in the case of
amaurosis above cited, that the arteria centralis retinae was spas-
modiciilly occluded for thirteen months? (3d). It has been found
by Gull that irritation of the renal nerves does not cause contraction
of the vessels of the spinal cord, nor paralysis of the lower limbs, as
Brown-Sequard stated in explanation of the paraplegia from renal
disease. (4th). In some cases of paralysis from exposure to cold
and wet — v. one related by Dr, Copland {Diet, of Pract. Med., art.
Paralysis, 76), the paralysis continues long after the exciting cause
has ceased, and is removed by stimuli applied to the sensory cutane-
ous surface. Here the paralysis must be non-organic ; and yet it
can scarcely be supposed to depend on anaemia of the centres result-
ing from arterial spasm. On the other hand, it is intelligible that

GENERAL PATHOLOGY. 25

the nerve- cells might be thrown into a state of enfeebled action by
the cold, &c., from which they could not easily recover. These
cases, though not typically inhibitory, seem to me very illustrative
of the nature of the morbid action.

(VI.) It is, I think, a matter of certainty, that a nervous centre
may be more or less completely paralyzed without having undergone
organic change, in consequence of some enfeebling morbid influence,
as the influenzal or malarious miasms, &c. Dr. GulP has published
a most interesting instance of complete paraplegia induced by sexual
excess, in which nothing abnormal could be detected in the cord even
by careful microscopy. This was paralysis from simple exhaustion.
Such paralysis may be distinguished as simple or neurolytic. I
think it is certain that this does not depend on local anaemia ; which
adds to the probability that inhibitory paralj'^sis does not either.

(VII.) Anatomically regarded, it is very remarkable how closely
the different nervous centres, or parts of a nervous centre, are con-
nected by commissural fibres ; and from a pathological point of view,
the same connection is often very manifest. The general exhaustion
induced by excess in venery, the reproduction of neuralgia in weakly
persons by bodily exercise, the effect of muscular exertion in pro-
ducing drowsiness, are examples which show how excessive con-
sumption of the nerve-force in one part weakens it also in others :
and \his can only be adequately explained by the intimate commis-
sural connection between the various centres. Tetanus is a good in-
stance of the diff'usion of a state of excitement from one part of the
cord throughout its whole extent.

(VIII.),;,The remarkable influence of the nervous system over the
bloodvessels requires some particular notice. Our knowledge on
this head has been chiefly the result of Bernard's labours; and it is
difficult to overestimate the importance of the study of these phe-
nomena to every physician who desires either to comprehend aright
the varying and manifold phases of disease, or to attempt the control
of morbid actions by remedies in a rational and satisfactory manner.
It is well known that in paralysis from disease of the brain or spinal
cord, the temperature of the paralyzed parts, as a rule, is lowered.
This was found to occur when the anterior or posterior roots of the
spinal nerves, or the root of the fifth pair, or that of the facial, were
divided. The loss was not very considerable, varying from about
3° to 7° F. When the sympathetic nerve in the neck was divided,
or the superior cervical ganglion extirpated, the following phenomena
were observed: The temperature of the operated side increased
rapidly, and in a quarter of an hour had risen 11° F. ; the arteries
and small vessels dilated, and became much more full of blood than
those of the opposite side; the pupil contracted, as well as the pal-
pebral opening, while the globe of the eye appeared depressed in
the orbit. The hypersemia, which is the immediate result of the

1 Guy's Hospital Pieports, 1858, Case xvii.

26 GENERAL PATHOLOGY.

operation, subsides considerably in a day or two; but the elevation
of the temperature is much more persistent, lasting in rabbits 16 to
18 days ; in dogs 6 weeks to 2 months. Not only the superficial
parts, but the deep-seated, and even the blood returning by the
jugular vein can be shown to be hotter than the corresponding parts
of the healthy side, or than they themslves were previously. It is
an important circumstance, observed by Bernard andBrown-Sequard,
that the temperature on the sound side falls below its previous figure,
the difference in one experiment amounting to 5|-° F. The pheno-
mena now described are more prominently marked in healthy and
vigorous animals than in those that are weakly, and in those that
are digesting food than in those that are fasting. When an animal
whose cervical sympathetic has been divided on one side is exposed
to a temperature above that of its own body, the side where the
nerve is entire gains heat, while the other remains almost unchanged,
and, before long, no difference can be detected between them. On
the other hand, when an animal similarly circumstanced is placed in
a medium considerably colder than its own body, the difference be-
tween the normal and the operated side becomes more prominently
marked. The former loses heat much faster than the latter, and
the thermometer shows it may become as much as 21° F. colder
than its fellow. If the upper end of the divided sympathetic is gal-
vanized, all the effects produced by the previous operation disappear,
and are replaced by their converse. The pupil dilates, as well as
the palpebral opening, and the eyeball projects from the orbit.
Instead of being active, the circulation becomes weak; the conjunc-
tivae, nostrils, and ears, which were red, become pale. Th^ tempera-
ture falls below the normal figure, while, curiously enough, that of
the opposite side increases notably. According to Brown-Sdquard,
the effects produced by a transverse lateral section of the semi-cord
in the dorsal region, on the posterior limb of the same side, are
exactly similar to those we have been considering. The condition
also of the opposite sides in both cases is quite similar; "both
receive less blood than usual, their temperature diminishes, their
nutrition is less active, and their vital properties also diminish."
By recent investigations, Bernard has found that there are two sets
of nerves in the cervical sympathetic — one occulo-pupillary, arising
in the dog from the anterior roots of the two first dorsal; and the
other vascular and calorific, arising from the sympathetic ganglia.
He also states that division of the anterior and posterior roots of
the nerves proceeding to the posterior extremity in dogs causes
paralysis of motion and sensation, but no change of temperature or
vascularity. Division of the sciatic nerve, however, raises the temper-
ature 6° to 8° C. (11° to 14° F.), and increases the vascularity.
Division of the sympathetic nerves has the same effect, but causes
no paralysis. Bernard's observations thus go to attribute more
importance to the proper fibres of the sympathetic system than to
those wiiich it receives from the spinal nerve in controlling the

GENERAL PATHOLOGY. 27

local circulation. They demonstrate, certainly, the partial inde-
pendence of the sympathetic system. Bernard remarks that though
he has watched for a length of time animals who had undergone
division of the cervical sympathetic, he has never seen any oedema
or inflammatory action supervene in the abnormally hot parts so
long as the animals continued in good health ; but if they fell sick,
either spontaneously or from the effects of other operations, the
mucous membranes of the eye and nose on the operated side only
became very red, swelled, and poured out purulent matter abund-
antly. If the animal's health improved, these inflammatory phe-
nomena ceased. This highly important observation I can quite
confirm from my own experience. A cat on which I operated had
severe purulent ophthalmia of the left eye for five or six days ; after
which it spontaneously declined. Sixteen days after the operation,
the left ear was 15° F. hotter than the right. She had been de-
bilitated by an unsuccessful attempt to divide the renal nerves on
one side.

The cause of the elevated temperature of the parts lying in the
range of the divided sympathetic is attributed by Brown- S^quard
and Waller to the increased afflux of blood to the local hypergemia.
Bernard, however, opposes this view, because the temperature does
not vary when the hyperemia declines ; because hyperaemia occurs
when the fifth nerve is divided, but is attended with diminished
temperature ; and because ligature of the veins of each ear, and
consequent gorging of the vessels with blood, lowers the temperature
of the parts, which again rises on the side on which the sympathetic
is subsequently divided. It is true, that if the carotid be tied, and
the sympathetic afterwards divided on the same side, no calorification
takes place; but if the sympathetic be first divided, and calorification
have come on, ligature of the carotid does not lower the temperature
to that of the sound side. Another argument which may be used,
in support of Bernard's opinion, is that the temperature in the para-
lyzed parts exceeds, in some cases, by 2° or 3° the normal temper-
ature of internal parts, as the rectum. On the whole, it seems to
me decidedly most probable that the increase of heat is not solely
due to hypergemic afflux, but that accelerated tissue change also
plays a considerable part in its causation. It is a very important
point, which is well illustrated by Brown-S^quard,' that the vital
properties of the tissues in the range of the divided sympathetic
are increased. He states that sensibility is augmented and persists
longer; the sense of hearing seems to be more acute; the secretions
of cerumen, tears, and perspiration are increased ; chloroform anaes-
thesia occurs later in these parts than in others ; the first convulsions
in strychnia poisoning take place there ; a galvanic current, too weak
to act on the other side, produces contractions there; after death,
the muscles and the iris remain contractile longer than usual ; the

1 Phys. of Central Nervous System, p. 141.

28 GENERAL PATHOLOGY.

galvanic current of the muscles, detected with the galvanoscopic
frog, is stronger than in those of the other side; cadaveric rigidity
comes later and lasts longer, and putrefaction ensues later. Bernard
doubts that the effect of dividing the sympathetic is to paralyze
the arteries, and so cause their dilatation ; he seems to regard it as
an anomaly that arterial paralysis should promote greater activity
of the circulation. This, however, seems only natural, when we
reflect that arterial contraction would necessarily have the opposite
eifect, and would diminish the afflux of blood to the part. This is
well seen when the arteries in the frog's web are made to contract
by the application of cold ; whole tracts of capillaries appear empty,
and deprived ef red corpuscles. On warming the web, the arteries
immediately pour in blood abundantly. The old and oft-used phrase,
"great arterial action," descriptive of a large and bounding pulse,
when translated into correct physiological language means, of course,
great cardiac action with a ivant of arterial. Some recent observa-
tions by Bernard,^ show very clearly how paralysis of the sympa-
thetic nerves increases and accelerates the arterial current. When
a manometer was inserted into the right coronary artery of the lip
of a horse, and another into the left, both instruments showed a
pressure of 160 to 180 millim. The pressure of the blood increased
40 millim. on the left side after division of the corresponding cervical
sympathetic. In the coronary veins of the lip, the instrument
showed a pressure of 30 to 40 millim., which increased to 50 or 60
after section of the sympathetic, while the pressure again fell 20
millim. when the nerve was galvanized. As other results of division
of the same nerve, were noticed pulsation of the veins, and a brighter
colour of the venous blood.

Analogous experiments made by other observers strongly corrobo-
rate Bernard's statements. Jaschkowitz shows that section of the
sympathetic plexus of the splenic artery causes congestion of
blood, softening and distension of the capsule. If part only of the
plexus is divided, the corresponding part only of the spleen is affected.
Samuel, in experiments upon rabbits, dogs, and cats, found that the
hypersemia of the intestinal mucous membrane produced by the
extirpation of the coeliac plexus was so great that it exceeded all
pathological hypersernias hitherto known. The secretion of the
mucous membrane is increased by the operation, but not to the
same degree as in violent diarrhoea. Wharton Jones finds that after
removal of the lower part of the spinal cord and the roots of the nerves
in a frog, the arteries of the webs retain all their contractility, or
are even more than usually disposed to be constricted. If now
the ischiatic nerve be divided on one side, "the result is, that the
skin of the extremity subjected to the experiment becomes, even to the
nal:ed eye, redder from vascular congestion than that of the opposite
extremity ; and, on examination of the web under the microscope,

^ ' La Clia. Europ. 1859, No. 29, p. 282. Syd. Soc. Year-book, 1861, p. 29.

GENERAL PATHOLOGY. 29

the arteries are found considerably dilated. In the web of the
opposite extremity, on the contrary, the arteries are seen still much
contracted, some even to closure.'' Instances have been observed
in man where like results have ensued. A man cut his leg with a
bay-knife ; profuse bleeding ensued, and nearly proved fatal. Ever
after he observes that the wounded leg is hot and moist, while the
other is apt to be cold. A patient of my own cut the inner side of
the index finger deeply ; and after the wound had quite healed I
found the distal part of that finger 2° hotter than the corresponding
part of the middle. Algide fever, where the surface is icy cold,
affords an example of the opposite state.

The above statements show, in the clearest manner, how consider-
able a control the sympathetic nerves accompanying the arteries
have over the circulation, and the nutritive actions in a part. It is,
therefore, certain that the influence of those vaso-motor nerves must
rank very high in the pathology of all disorders attended with al-
terations of the circulation. But, we have now to inquire whether
these are the only nervous organs which act on the circulation, or
whether there exist others also. The answer to this last question
must be in the afiirmative. Ludwig's and Bernard's experiments
show convincingly that stimulation of the third division of the fifth
pair, and of the facial produces a greatly increased flow of saliva,
while at the same time the circulation in the gland is accelerated.
It is not known so certainly whether this is the case with other
glands ; but with regard to muscles it seems sufficiently evident
that their voluntary exercise coincides with increased blood-flow.
The darker colour, increased bulk, firmness, and strength of a muscle
that has been well exercised contrasted with the paleness, flaccidity,
and wasted condition of one that has been long unused, can be ac-
counted for in no other way than by admitting that the former has
received a much larger supply of blood. If any further evidence
were required, it would be found in the observations of Becquerel
and Breschel, as to the increase of temperature which is produced
by muscular exercise, amounting sometimes to 2° F. The pheno-
menon of erection of the penis is, beyond doubt, dependent on a state
of active innervation of the part causing increased afflux of blood.
At certain times its occurrence can be perceived to be distinctly
voluntary, and can be induced or prevented at the will of the indi-
vidual. SamueP contends for the existence of fibres, distinct from
the motor of muscles and vessels, as well as from the sensory, whose
office is to preside over nutrition, and which are divisible into a
centrifugal and centripetal set. The former, when excited, increase
nutrition, when paralyzed decrease it. Paralysis of the centripetal
fibres Samuel regards as the cause of the diminished resisting power
of anaesthetic parts to injuries, &g. Fever and inflammation he

' Die tropMsche Nerveu, Leipzig, Wigaud, 1860. Canst. Jahresb., vol. ii. pp. 53-57,
1861.

30 GENERAL PATHOLOaY.

explains as states of excitement of the trophic nerves. He records
various experiments in which irritation of sensory and of compound
nerves caused intense inflammation of the parts to which they were
distributed. Thus irritation of the auriculo-temporal in the rabbit
produces acute inflammation of the whole auricle, issuing in puriform
eifusion, and inducing death by exhaustion. This inflammation did
not begin until from three to six days after the operation, and most
evidently was not traumatic. Irritation of the gangliform plexus
of the vagus on one or both sides caused general and intense pneu-
monia. From these statements, I think we cannot doubt that cer-
tain nerves, when stimulated, do exert a very considerable influence in
the districts to which they are distributed, in the way of increasing
the amount of blood circulating through the tissues. Herein they
exactly antagonize the ordinary vaso-motor nerves accompanying
the arteries, whose activity induces the opposite condition. For
the present it must remain doubtful whether these so-called trophic
nerves are indeed a special set, or whether the same efi"ects may not
be produced through ordinary motor and sensory nerves. The latter
view seems the most probable, and is strongly corroborated by the
atrophy of the hands and feet, which occurs as the result of the
ansesthesia of Indian leprosy.

(IX.) Some common facts, of daily occurrence, are worth consi-
dering in reference to the above doctrines. It seems that there
exists a kind of alternation between the action of the vaso-motor
and cerebro-spinal nerves, the period of activity of the one corres-
ponding to that of quietude in the other. Thus, while we remain
at rest, the temperature of the surface of the body generally, and
especially that of the limbs, is decidedly lower than when we are in
active exercise, and the cutaneous bloodvessels are comparatively
contracted and small. This condition, when it is somewhat excessive,
produces the cold hands and feet from which not a few persons suffer.
On the other hand, there are instances, though less frequent,
where the reverse seems to be the case, and the hands and feet are
prone to be hot and bedewed with excess of secretion. In the former
it is clear that the cutaneous arteries are habitually contracted, in
the latter relaxed. Now, it is certainly remarkable that voluntary
exercise of the muscles should so speedily aff'ect the distribution of
blood to the cutaneous surface. We might have expected that it
would have caused an increased flow to the muscles, according to
the function assigned to the trophic nerves ; but we should scarcely
have surmised a priori that an active state of the musculo-motor
would coincide with a paretic of the vaso-motor nerves of the integu-
ment of the same limb. The fact, however, is unquestionable, and it
is worth inquiring how it comes to pass. There seems no other ex-
planation than that the vis nervosa of the centres, which while the
muscles are at rest can act only on the vaso-motor nerves, is with-
drawn from the latter to a great extent when these great organs are
put into action, and, consequently, the cutaneous and other arteries

GENERAL PATHOLOGY. 31

become dilated and permit free access to the blood. That this is
really the case is tolerably clear, I think, from the circumstance
that not only the vessels of the integument of the working muscles
are relaxed, but those also of distant parts, as the head, which are
not specially active. A rower, or a pedestrian wending his way up
a mountain pass, finds the toil-drops fall thick and fast from his
brow, though his brain is far less active than it was when he was
engaged in his study. The influence of cold also goes far to prove
that the relation of the phenomena to each other is such as I have
suggested. It is certain that in cold weather we are capable of
much more muscular exertion than in hot. On a cold day we can
walk briskly with a weight of clothing which would be intolerable
on a warm ; the cold evidently increases our muscular force. At
the same time, we find that our limbs do not warm nearly so readily,
though they may be well wrapped up, and sensible perspiration is
with difficulty induced. This is because the greater amount of vis
nervosa not being so soon expended on the voluntary muscles, keeps
the arteries longer contracted. Again, it is well known that horses,
who are in good training, will do their work with much less sweating
than those who are out of condition. Patients suffering with neuro-
lytic disorder often complain that the least exertion causes them to
break out into perspiration, while, as they improve, this tendency
diminishes. Here, again, we see a positive relation between nerve-
power and vascular dilatation. The increased secretion from the
cutaneous surface may be reasonably supposed in a state of health
to be the result of an increased supply of blood to the perspiratory
glands, and we have already seen that such has actually been found
to result from the hypersemia induced by dividing the vaso-motor
nerves. We may, therefore, I think, fairly surmise that what takes
place on the cutaneous expansion and glands takes place also in in-
ternal lining membranes and glands, and that thus by means of the
free flow of blood to all parts the general nutrition is more per-
fectly carried on.

One chief cause of arterial dilatation, when the muscular coat is
relaxed, is of course the pressure of the column of blood driven by
the heart. Now, during exercise the action of the heart is increased ;
and it is interesting to inquire how this occurs. Moleschott's ex-
periments show that a weak stimulus applied to the vagi increases
the frequency of the pulse ; yet it is also almost the universal testi-
mony of all observers that division of these nerves greatly acceler-
ates it. In one experiment of my own, the rate was nearly doubled.
It seems, therefore, that paresis of the vagi may be looked upon as
a probable cause of acceleration of the heart's action ; and this
paresis would be produced in the same way as that of the arterial
nerves. Moleschott asserts that the sympathetic has the same in-
fluence on the heart as the vagus, so that all the cardiac nerves
would be affected in the same way. Moreover, paresis of the coro-
nary plexuses would have the effect of admitting a larger supply of

82 GENERAL PATHOLOGY.

blood througli these arteries to the muscular tissue of the heart.
This would certainly favour, if it did not set up, increased action of
the organ. There exists evidence to show that heat has a stimu-
lating effect on the movements of the heart ; and it is probable that
the increased temperature of the blood in febrile states is concerned
in causing the rapid pulse. But the acceleration of the heart's
movements by muscular exertion ensues too rapidly to be ascrib-
able in any great degree to this cause. In feeble persons, palpita-
tion and quickening of the pulse on any slight muscular effort are
familiar occurrences ; and it may be said generally, that the greater
the debility, the more readily does the change in the cardiac rhythm
occur. There can be little question that the two phenomena are
really related to each other, and it is difficult to see any more prob-
able connection between them than that which I have suggested. It
is evidently in accordance with the plan of the circulation, that dila-
tation of the arteries should concur with increased action of the
heart. If the reverse was the case, we should have the heart's
energy wasted in endeavouring to overcome the undue resistance
of the vessels. As it is, however, the central impelling organ puts
forth its activity at the time when it can be really effective. Some
of the phenomena of disease accord remarkably with the above views.
The rapidly-acting heart of the patient prostrated by low fever is
often greatly quieted by wine. The quick, feeble, irregular pulse
of cardiac dilatation is not unfrequently made steadier, slower, and
stronger by digitalis, which is certainly a cardiac stimulant. The
degree of acceleration of the pulse produced by sitting up in bed
is a good indication of the extent to which a patient is exhausted
by fever, or any other asthenic disease.' In the affection termed
"goitre exophthalmique," the heart's action is often remarkably ex-
cited, the carotid and thyroid arteries uncontracted, while the gene-
ral condition is mostly one of great, perhaps extreme, debility.

The application of cold to the cutaneous surface exerts, as is
well known, a striking influence on its contractile tissue, producing
the so-called goose-flesh. This is not (at least necessarily) the result
of direct stimulus, as it is equally produced when the cold is applied
to another part of the surface. Thus, a cold wet towel flapped oh
the back immediately causes contraction of the cutaneous muscles
on the anterior part of the trunk, which, of course, can only take
place in a reflex manner, the stimulus of the cold to the sensory
nerves being reflected on the vaso-motor, and those which influence
the cutaneous fibres. This contraction, it may be remarked, is pre-
cisely the same to all appearance as that which results from direct
stimulation of the tissue by the interrupted current. It seems
highly probable that the same contraction of organic muscular fibre
takes place in internal parts when cold afFusion is applied to the
surface, since there is no reason why we should suppose the stimu-

' Graves, Dublin Hospital Reports, 1830, v. p. 469.

GENERAL PATHOLOGY. 33

lant impression to be reflected on the nerves of the skin alone.
Indeed, there is actual proof that such is the case ; for we find that
the heart's action is notably influenced by the cold shower-bath.
Dr. Sieveking states that when the bath was taken after the pulse
had been increased by exercise, the average depression in twenty
observations amounted to 8.05 beats. When the bath was taken
immediately after rising, the average depression in thirty observa-
tions was 6.14, and this was not counteracted by subsequent exercise,
which only increased the pulse on an average by 3.21 beats. These
results were obtained upon a person in good health, and in whom
sufficient reaction occurred ; but it is probable that in a less vigorous
subject the depression would have been still greater. In fact, what
happens when reaction is insufficient seems to be this — that the
heart's action continues depressed, and the arteries generally con-
tracted, so that free flow of the blood-current is prevented. The
depressing action of the bath should be but temporary, and should
be succeeded by the opposite condition. Dr. Brown-Sequard avails
himself of this natural tendency of the vaso-motor nerves in his
recommendation of the alternate application of cold and heat to
procure the healing of bed-sores arising from defective circulation.
Dr. Bence Jones's observations as to the effect of prolonged cold
aff"usion show that it has a most powerful sedative eff'ect on the
heart, reducing the pulse thirty to fifty beats in a minute, and often
rendering it quite imperceptible. When the water was cooled down
to 50° F., the eff'ect was much more rapid.

In the treatment of acute mania, the cold douche has long been
recognized as a most efficient sedative to an excited nervous system ;
and, indeed, much judgment may be requisite so to employ it as not
to induce serious, or even fatal depression. A patient of Dr. Currie's,
who had derived benefit from cold affusion during the hot stage of
an ague-fit, nearly died from the alarming depression which resulted
from the same application while he was in the cold stage. The facts
now referred to set in a clear light the great influence which the
state of the nervous centres has on the results produced by the
impressions conveyed to them. The latter may remain the same,
but the effects will vary greatly according to the condition of the
recipient centre. Thus, the shock of cold speedily causes in one
person activity of the circulation and vigorous action of the heart ;
while in another the primary depression persists, and is never suc-
ceeded by the opposite state. It is a point well worth remarking, that
when the arteries are contracted by cold, the capillaries and veins
are often filled with stagnant venous blood. This condition may
sometimes be well seen in the frog's web; and we may then observe
how speedily the congestion is dissipated by warming the web and
relaxing the arteries, so as to allow free blood-flow to take place.
A good example of this kind of congestion was presented to me the
other day in a man suff'ering from a small abdominal aneurism. An
ice-bag had been applied over the tumour, and all the area of in-
3

34 GENERAL PATHOLOGY.

tegument where it lay was of a dusky venous red, wliile the sur-
rounding skin was quite pale. On laying my warm finger on the
chilled skin, the venous hue quickly disappeared from that part. The
foregoing remarks illustrate the converse occurrence to that first ex-
amined; they show how depression of the heart's action, the result
of a stimulus, coincides with constriction of the arteries. The ob-
servations of Drs. Bence Jones and Dickinson^ are very interesting
as to the effect of a very hot vapour-bath taken just before the cold
douche. They found that the increased action of the pulse produced
by the exposure of the body to hot steam prevented that depression
which would otherwise have arisen from the cold water. The action of
heat is certainly relaxing to the muscles of the skin and the arteries ;
so that it is quite intelligible how in the above experiment it should
have obviated the over-stimulating eftects of the cold — rendering
both the coronary arteries of the heart, as well as those of the body
generally, less prone to constriction.

(X.) The relation which the febrile state bears to disorder of the
nervous system is a topic of high interest. It did not escape the
notice of Hippocrates, as shown by his aphorism, Uvpstoi %vst artaaixovi.
The essential phenomena of fever seem to be increased temperature,
more or less prostration, and derangement of the nervous functions;
disorder of the secretions, and impairment of nutrition generally.
The intention of the following remarks is not, of course, to notice
any particular kind of fever, but to endeavour to trace the extent in
which the phenomena of fever in general can be explained in refer-
ence to neuro-pathology. Debility of the cerebro-spinal system does
not seem, per se, capable of producing fever. We see patients con-
tinually who are extremely weak, with a small and languid pulse,
yet quite without fever. On the other hand, mere exhaustion from
muscular exercise does seem sometimes to set up fever. I know
myself two individuals in whom this has occurred. Again, all the
phenomena of the earlier periods of fever are indicative of depression ;
and in the prevailing fevers of our day, the stamp of debility is
apparent throughout. There is much in the facts above stated as to
the influence of the vaso-motor nerves to suggest that paralysis or
weakening of their power may be an essential condition in fever.
If we suppose the effects produced by dividing the sympathetic in
the neck to be general, to occur all over the body — which is quite
conceivable — there would ensue general pyrexia. In fact, we are
sure that elevation of temperature and relaxation of arteries cannot
exist with any other than a paretic condition of the sympathetic.
Taking first for consideration the ordinary low or asthenic fevers,
with which we are familiar, let us see how far "we can account for
their phenomena on the assumption that the poisonous miasma has
weakened the vaso-motor system, as well as all the others. The
increased temperature — the quick, but soft and weak pulse — the

Vid. Proc. of Med.-Chir. Soc, yoI. i. p. 77, 1857.

GENERAL PATHOLOGY. 35

hyperoeraias of various viscera, may all, according to the foregoing
views, be regarded as natural results. The increased secretion of
urea may be accounted for partly by the augmented chemical
changes which take place in the mass of the blood (considered for
the time as a solid tissue) uncontrolled by the sympathetic nerves,
and partly by the increased amount of renal action, depending on
the same cause. ^ The hypertrophy which affects the glandulse soli-
tarige and agminatge in typhoid may be also traced to the same ner-
vous paresis, and may be regarded as analogous to the enlarged
spleen of ague, or the goitre of Swiss malaria. To regard this
hypertrophy as an attempt at elimination seems to me quite a mis-
take. It is no more to be considered such than the enlargement of
the correlated mesenteric glands is, which takes place at the same
time. Both are similar structures, and both hypertrophy under the
same conditions, viz., hyperasmia and loss of nerve influence. The
condition of the other systems in low fever quite corroborates our
assumption as to the condition of the sympathetic. The quiet mut-
tering delirium, the unconsciousness or half consciousness, testify
how the brain is enfeebled ; while the down-sunken posture in bed
and the subsultus reveal the extreme muscular debility. The feeble-
ness of the heart's action and the softening of its texture prove how
its vital energy is depressed. The readiness of the skin to slough
shows how its nutritive power is impaired. In certain cases, it
seems as if the sympathetic system was but little affected, and the
main stress of disease fell upon the cerebro- spinal. This one may
conclude to have been the condition in the instances mentioned by
Graves'^ {v. loc. cit.), where he says, " It was very curious to see a
patient with a skin of a natural temperature, a perfectly natural
pulse, tranquil respiration, clear eyes, no headache, a soft and fallen
abdomen, incoherent, or with a low muttering delirium, excessive
subsultus, extreme debility."

Let us now turn to the opposite type of fever, the sthenic, marked
by strong, frequent, full or hard pulse, dry hot skin, intense head-
ache, active delirium, laboured respiration, diminished or suppressed
secretions, in which bloodletting is not only tolerated, but may be
essential to the preservation of life. It is evident that in such cases
the greater part of the organs must be in a very different vital state
to that which exists in low fever, where stimulants are for the most
part of prime necessity. Let it be assumed that the poison acts
primarily upon the sympathetic system, limiting its action to it, as
woorara does to the motor nerves: increased heat will be developed,
and subsequently a tendency to local congestion, varying in situation
according to the part where the paralysis is greatest. The increased
temperature of the blood will act as a stimulus to the heart, whose

• Oppler has shown that the kidneys actually form a considerable proportion of the
nrea secreted. Virch Archiv. vol. sxi. part 3. Syd. Soc. Year-book, p. 219, 1862.
2 Clin. Med., p. 157.

86 GENERAL PATHOLOGY.

tissue is vigorous (not debilitated, as in asthenic fever), and capable
of responding energetically. The heart's action will thus be in-
creased, and thus the character of the pulse is explained, except as
relates to its hardness — a point we shall presently notice. The very
interesting experiments of M. Calliburc^s, mentioned in Bernard's
Lecons (vol. ii. pp. 395 — 403), corroborate the opinion advanced
above, that the increased heat of the blood is the cause of increased
cardiac action. He found that when the leg of a frog was dipped
into warm water, the heart constantly contracted more frequently.
Thus, the number of pulsations in three separate trials being 52, 32,
42 at the commencement, a temperature of 51°, 50°, 55° raised
(respectively) the number of the beats to 90, 64, 100. Similar
results were obtained when the heat was applied directly to the
heart. Ligature of the vessels and section of the crural nerve did
not prevent the increase of cardiac action from the application of
heat to the leg. He concludes that the acceleration of the heart's
action by heat is owing to the direct action of this agent upon the
circulatory centre. That a high external temperature, which nota-
bly raises that of the body, quickens the pulse, is certain. Blagden,^
on exposing himself for eight minutes to a temperature of about 260°
F., found his pulse rise to 144 ; and Constantine James, ^ in hot moist
air of about 100° F., found his pulse to reach 120, while his tem-
poral arteries beat forcibly. The acceleration of the pulse may be
owing in part to the enfeebling influence of the poison affecting the
vagi nerves ; but the increased strength of the heart's contractions
must depend on the dilatation of the coronary arteries and the free
circulation of blood through its muscular tissues, whose vital power
is thus temporarily increased. The hardness of the pulse in certain
(sthenic) fevers and inflammations, implies a contracted state of the
arterial coats. This, if general, is an opposite condition to that
which is produced by section of the sympathetic, and, therefore,
demands explanation in an hypothesis which is based on a presumed
palsy of the system. It is to be remembered that arterial dilatation
is by no means inseparably connected with increased blood-heat ;
that the latter persists when the hypergemia, which the former occa-
sions, has materially subsided. In sthenic fevers, it may fairly be
presumed that the arterial coats, like the heart, retain for a time
excitability, and contract, therefore, moderately under the direct
stimulus of the rapid blood-current which traverses them. The
pulse is, therefore, hard. In low fever, on the contrary, the pulse
is soft, because the poison impairs at once the vital power of the
arterial coats, as well as that of their vaso-motor nerves.

Pyrexia, or the fever of inflammation, may next be considered.
It is, probably, excited by a morbid impression conveyed from the
inflamed part to the sympathetic centres ; in consequence of which,
by a reflex inhibitory action, the vaso-motor nerves generally are

' Brewster's Nat. Magic, p. 311. * Gaz. Medic, April 27, 1844.

GENERAL PATHOLOGY. 37

enfeebled, and so, as in other cases, fever results, with increased
cardiac action. The production of pyrexia is the ordinary case ;
the exceptional is that already mentioned [vide p. 22), where irrita-
tion in some organ occasions paralysis of musculo-motor nerves. On
the view just proposed, it is intelligible why the administration of
tonic and nervine medicines is injurious in the pyrexia of sthenic
inflammation, while it is beneficial in that of asthenic. The inflamed
tissue being highly sensitive and impressionable, becomes further
irritated by the tonic remedy ; and so the morbid impression con-
veyed to the centres, and reflected on the vasomotor nerves,
becomes intensified. By the employment of tissue sedatives, on
the other hand, the morbid stimulus is annulled, and the fever
movement subsides. This view assumes as certain a point which,
though admitted by most of our best authorities, seems to be often
ignored in the present day. I mean the existence of forms of dis-
ease which, though aff"ecting the same part, and called by the same
name, are as essentially dift'erent in their nature and tendencies as
can possibly be — and this, too, independently of the original vital
power of the patient. The distinction between sthenic and asthenic
forms and phases of disease seems to me to be one of the leading
truths in medicine ; and I cannot conceive how any one with the
evidence of his daily experience before him, can think lightly of it.
To take but one instance. It is unquestionably true that cases of
erysipelas do occur, mostly among the rural population, where free
venesection is positively beneficial, as well as purging and other
lowering means. On the other hand, we frequently have to treat
cases of the same disease where the only indication, and that an
urgent one, is to stimulate very freely. The outside show of these
cases is very similar, but how dift'erent are they in reality ! Sthenic
disease is by no means synonymous with acute; the latter term has
reference chiefly to the rate of progress, and may belong quite as
well to asthenic as to the opposite class. One highly important
character of sthenic disease is the state of the tissues with respect
to their tolerance of any matters conveyed to them which are at all
of an exciting quality. Let the skin be sthenically inflamed, as in
eczema impetiginodes, and the arsenic or citrine ointment, which
would benefit another case of a different temper, will grievously
aggravate the disorder. On the other hand, when, in suitable cases
of this kind, leeches, lead-lotion, salines, and antimonials have done
their work, the same remedies which before were injurious prove
healing. This is so because the vital condition of the tissue is now
changed. Much of the " tactus eruditus" of the physician consists
in being able to determine what cases belong more to the sthenic
and what to the asthenic class, and in adjusting his remedies
accordingly.

The cause of the rigors of fever is a question of some interest.
The phenomenon clearly belongs to the nervous system, and must

38 GENEKAL PATHOLOGY.

be regarded as a kind of minor convulsion.^ It can be produced by
various morbid impressions made on sensitive surfaces, as when a
catheter is passed along a hyper^esthetic urethra, or, as in the case
mentioned by Dr. Watson, where immersion of a recently-scalded
arm in cold water brought on severe rigors. The forcing of a gall-
stone along the narrow duct may have the same effect ; and so may
a descending renal calculus. I have found, in my own person, very
extensive irritation of the skin from harvest bugs produce even
during very warm weather distinct though slight shivering. Simi-
lar shivering was observed in the early part of catarrhal fever, evi-
dently connected with cutaneous hyperiesthesia ; the sensation of
coolness, which in health would have been very agreeable, being
then actually repugnant. In malarious and other fevers the initial
rigor is probably dependent on the action of the poison on the spinal
cord, throwing it into a state of undue excitability, so that the nerves
issuing from it keep the muscles in a state of clonic contraction,
while the vaso-motor nerves maintain the organic muscles in a state
of tonic. The same influence thus produces varying effects, accord-
ing to the structures on which it acts. The rigors of pyaemia and
of suppurating foci I should ascribe to the operation of contaminated
blood on the nervous centres, and regard them, therefore, as having
a similar causation to those of ague. On the other hand, those of
hectic fever are most probably essentially dependent on nervous
exhaustion, the centres falling into a state analogous to that existing
in chorea, but manifesting itself in disordered actions of the vaso-
motor more than of the musculo-motor system. Generally, there
seem to be three factors concerned, or liable to be concerned, in the
phenomenon: (1), a stimulus mostly of a morbid kind; (2), an altered
hypersesthetic condition of a sensory surface; (3), a more or less
excited or mobile condition of one or more nervous centres. In
most cases the coexistence of two of these is necessary. Billroth^
states with regard to the rigors attending on fever of surgical affec-
tions, that their principal condition is a very rapid increase of
temperature ; another is a peculiar irritability of the patient, which
may vary much in different cases, or in the same case at different
times. He does not consider the rigors in pyaemia as necessarily
dependent on blood-poisoning. There is no doubt that increased
heat of the blood most frequently coincides with rigors ; but inas-
much as they may occur where there is no fever {vide supra), and
vice versa (as in an ague paroxysm having no cold stage), it seems
to me most probable that the increased temperature is only a Co- pro-
duct of the original cause. The poison by paralyzing the vaso-motor
nerves causes fever, and by acting on the nervous centres produces
rigors. Here we have an example of the generation of spasm and
paralysis by the same cause.

• Mr. Paget relates cases in which tetanic or epileptiform seizures took the place of
rigors; v. Brit. Med. J., Aug. 16, 1862.
2 Via. Syd Soc. Year-book, 1863, p. 193.

0ENEKAL PATHOLOGY. 39

(XL) We may now pass to the consideration of some general
points in reference to neuralgia ; a condition which in many respects
contrasts strongly with fever, and rarely coexists with it. Schramm/
however, states that the remittent form of sciatic neuralgia in his
experience has been generally attended with fever, and in many
cases all the three stages of a paroxysm of fever (malarious) have
occurred. The opposition of the two states is well manifested in
some cases of malarious fever, where one febrile paroxysm in a
series is, as it were, replaced by an attack of neuralgia. This, as
well as the common production of some form of neuralgia by malaria,
goes far to warrant the view that the morbid phenomena are deter-
mined very much by the part on which the poison fixes ; pain ensu-
ing if the cerebro-spinal nerves are specially attacked, fever if the
vaso-motor, the exciting cause in both being the same. The preva-
lent opinion respecting the nature of neuralgia seems to be that its
existence implies an excited or over-active condition of the sensory
nerves. Romberg uses neuralgia and hyperaesthesia as convertible
terms, and states — in hypersesthesia we find that not only the irrita-
tion is increased, but that also the irritability of the nerves of sensa-
tion generally is exalted both during the paroxysms as well as the
intervals. It is very evident that we can have no knowledge from
actual observation of the state of the affected nerves during the
attack. We must form our conclusions as best we may from con-
sideration of the attendant circumstances, the "juvantia," and the
relation of the disorder to others. For the moment let us put aside
all cases of neuralgia which maybe regarded as depending on a
local irritation of any kind — either direct, as a splinter imbedded
in a nervous trunk ; or remote, as a worm in the bowels ; or, again,
on demonstrable poison generated in the system, as in gout, or
received into it, as in lead intoxication. There remain, then, all
those cases in which the disorder is dependent upon no ascertain-
able cause, except it be malaria, a draught of cold air, exposure to
damp, overwork of mind or body, or some other cause of exhaus-
tion. These form a group which may be distinguished as Non-
organic or Immaterial Neuralgia. Now, in these the existing
debility and prostration is at least very often almost as marked a
symptom as the pain. It is also more abiding and unvarying ; and
the conviction becomes wrought in the mind of the observer that it
is the fundamental state upon which the pain is, as it were, en-
grafted— the appropriate soil, without which the morbid germ would
not grow. It is proved by experience that unless this debility and
prostration can be to a great extent removed, and replaced by
healthy vigour, no real progress ,can be made in the cure of neu-
ralgia. The task is like that assigned to Sisyphus : the patient's
and the physician's hope is worn out by ever-recurring relapses.
The debility seems in a special manner to affect the nervous system.

' Bayer, Arztl. lotelL, Bl. 34, 1859.

40 GENERAL PATHOLOGY.

The brain is languid and dull, and inapt for mental labour ; some-
times its function actually fails, and delirium occurs. Stimuli are
beneficial — often very markedly so, thougli their effect is temporary.
Fresh pure air, good food, sufficient repose, alternating with exhila-
rating employment, supplemented, if need be, by nerve-tonics, are
the real remedies ; and just in proportion as they increase the
general tone and strength, does the patient attain complete recovery
and immunity from relapses. On the other hand, just as surely do
all causes of debility confirm, increase, and render inveterate the
malady. Now, it may be fairly argued that where the signs of
debility, and specially of nerve debility, are so apparent, and have
so distinct a relation to the particular symptom, this must be itself
of like essential character. It can hardly be that the morbid state
of the nerve affected can be greatly different from that which pre-
vails so generally throughout the system, especially when we con-
sider the means which avail for the cure of both. Rombero-'s
metaphorical expression with regard to aneemic hypera3sthesia (neu-
ralgia), that "it seems as if pain were the prayer of the nerve for
healthy blood," is in all probability exactly true. The nutrition of
the nerve being ill performed, its structure undergoes some mole-
cular alteration which conditionates pain. What is true of neuralgia
from this cause, I believe is true of all cases belonging to the im-
material class. Electrical disturbances, damp cold, malaria, seem
to me all to act in the like way, as far as we can judge — viz., by
deranging the molecular nutritive actions of the nervous structure,
and so unfitting it for fulfilling its function. There are several
circumstances which seem to me strongly to support this view. One
is the very frequent coexistence of numbness along with the pain,
especially in highly sensitive parts, as the fingers and hands. One
cannot say wherein the condition producing numbness differs from
that which gives rise to pain ; but it is clear that there is no opposi-
tion between them : both are often present together, and the numb-
ness commonly remains as the more permanent condition in the
intervals of the paroxysms of pain, and even after they have
ceased to occur. Now, numbness is evidently a failure of functional
power. Of the same import is the occurrence of various degrees of
muscular paralysis, which is often associated with neuralgia, evi-
dently as an analogous affection of the motor nerves. It yields
generally to the same treatment. The phenomena of myalgia may
also be referred to in illustration of the nature of neuralgia. Here
the intimate relation of pain to debility is very marked : the sensory
nerves of the muscles suffer because the associated motors are weak:
whatever increases the debility increases the pain, and vice versd.
In many well-marked neuralgic affections there is evident paralysis
of the vaso-motor nerves in the seat of the pain ; the vessels are
injected, and lachrymation or some similar phenomenon ensues. This
makes it probable that the sensory nerves are in a similar state.
Lastly, we may allude to the cure of neuralgia by Faradization as

GENERAL PATHOLOGY. 41

an illustration of its nature. The pain of a sensory nerve and the
paralysis of a motor may both be removed by the stimulus of the
interrupted current. This surely indicates that both states are
similar. Even in organic neuralgia, it seems to me open to much
question whether the affected nerve is in a state of exalted excita-
bility, or simply of deranged and disordered nutrition. In lead-
poisoning, the motor-nerves of the muscles are certainly paralyzed,
the pains are diminished "by pressure and friction" (Romberg), and
the whole phenomena are indicative of diminished rather than of
increased vital action. In gouty neuralgia, if we take colicky
and spasmodic affections for examples, the disorder is much more of
an asthenic than of a hyperaesthetic character. The pain and
suffering attending a characteristic outbreak of gout in the foot
have much more the features of hypersesthesia than the colicky
disorder. The latter usually requires some stimulant for its relief,
and can by no means be dealt with as the articular inflammation.
, That a nerve which receives for nutrition blood poisoned by uric
) acid should be disordered in its acting, and thrown into a state
, conditionating pain, is very intelligible ; but it can hardly be re-
garded as having its functional power exalted. On the other hand,
the nerve lying in a focus of inflammation by reason of the active
hyperaemia would seem really to be in a state of hypersesthesia.
Its condition is analogous to that of the nerves of one posterior
limb in Brown-S^quard's experiment of transverse semi-division of
. the dorsal cord, where hypersesthesia is produced in consequence of
the hyperasmia resulting from paralysis of the vaso- motor nerves.
Again, where neuralgia results from the impaction of a spiculum of
bone, the development of a tumour or the like in a nervous trunk,
although severe pain may be produced, it does not seem very clear
that the nervous irritability is necessarily exalted — i. e., that the
nerve-filaments, either on the distal or proximal side of the irritant,
are more sensitive than they would be naturally. In a case of
neuroma of a portion of the auditory nerve recorded by Mr.
Toynbee,^ the only symptom was a diminution of the power of hear-
ing. In a case reported in the Duhlhi Medical Journal,^ a female,
set. 27, had a neuromatous tumour of the size of an almond developed
in the course of the median nerve. If anything, even her dress,
touched the tumour, severe pains shot down to the hollow of the
palm, and upwards to the shoulder. She complained much of numb-
ness and coldness of all the parts of the hand supplied by the
median nerve. The nerve was cut across, and the neuroma re-
moved. Fifteen months after the operation, she was quite free from
pain, and observed nothing abnormal except a remarkable coldness
of the fingers supplied by the median nerve. It is clear in this
case that the neuroma, while it occasioned pain, did not increase
the sensory power of the nerve. In some cases, however, it is

» Patholog. Soc. Report, 1851. 2 Dublin Med. Journ., May, 1848.

42 GENERAL PATHOLOGY.

certara that the peripheral nervous filaments are truly liypersesthetic,
as in the case related by Romberg (vol. i. p. 37-44). In this, how-
ever, the hypersesthesia may be accounted for by the increased
supply of blood sent to that side of the face, the arteries pulsating
strongly, and the eye being bloodshot and prominent. The same
explanation applies to many other cases where the neuralgia is
complicated with hypergestbesia, but not to all. In any case where
the sensitive power of a surface appeared to be actually exalted, so
as to be unusually keenly alive to the contact of external bodies,
there would, I think, be reason to look particularly to the state of
the nervous centres. Hysteria, hydrophobia, tetanus, and certain
toxic conditions, afford good examples of central hypersesthesia.
At the same time, I think it must be admitted that there is also
such a condition as peripheral hypersesthesia, of which we have
examples in photophobia, gastric irritability, and cutaneous pruritus.
This is certainly a very different state from neuralgia, especially in
relation to remedies, but has affinities with it. It occurs under
nearly the same causative conditions. Hypersemia from vaso-motor <
nerve paralysis is by no means a necessary antecedent. The above •
view respecting the nature of neuralgia and hypereesthesia is strongly
supported by the occasional occurrence of acute pain and tender-
ness in limbs afi'ected with embolism of the main artery. Motor
and sensory paralysis are constant, but in some instances there is
also pain and hypersesthesia. Mr. Erichsen describes arteritis as
attended with excessive sensitiveness of the surface, and with deep-
seated burning and lancinating pain striking through the limb in
different directions. The hypereesthesia persists even after the limb
has begun to get cold and pulseless.

From the preceding discussion we pass to the question — What is
the seat of neuralgia — the nerves or the centres ? Obviously, this
is no easy question to answer. According to the law of eccentric
phenomena, every sensation of which we are conscious is referred
to the peripheral termination of the sensitive fibres (so Romberg
writes). Bowman and Todd add, that the sensation is referred to
those parts, and to those only, to which the fibres irritated are dis-
tributed. According to this view, all appreciation of sensations as
referred to any point in the course of the nerve is out of the ques-
tion. An irritation, wherever set up, must be felt at the peripheral
extremity of the fibres implicated, and never in any part of their
intermediate course. But there are facts which seem strongly op-
posed to this exclusive dogma, and which go to prove that a sensation
may be referred to various points in the course of the nerve-fibres.
If we hit our funny-bone, although, no doubt, pain and tingling are
felt at the peripheral distribution in the fingers, yet the chief agony
is in the trunk of the ulnar nerve at the part struck, and certainly
not merely in the skin covering it. The circumstance dwelt on by
Valleix, that the specially painful points in nerves affected with
neuralgia are always those where the nerve becomes superficial, is

GENERAL PATHOLOGY. I 43

also a proof of a sensation being referred to other points besides
the terminal. The same may be said of the pains •which patients
describe as shooting down along the track of a nerve, as often ex-
emplified in sciatica. These certainly are not located merely in
the skin which covers in the nervous trunk. From these considera-
tions I am led to admit the possibility of very numerous exceptions
to the law of eccentric phenomena, and to believe that pain in a
nerve may really indicate by its situation the seat of the irritation,
or rather morbid action. This is a conclusion of some importance
to the local treatment of neuralgia. It justifies our empirical habit of
applying sedative remedies as near as possible to the seat (apparent)
of pain. But, of course, we cannot affirm in any case of pain involving
the trunk of a nerve that the morbid action may not be central ; the
law of eccentric phenomena holds true, so far as that central disorder
may certainly give rise to peripheral sensation. The only certain
means of distinguishing the site of the pain causing action is division
of the affected nerve. If this arrests the neuralgia, we know the
disorder is seated peripherally ; if it fail to do so, we know that we .
have to seek more centrally. In a very large number of cases, I
fear, it must remain problematical where the real seat of the disorder
is. If — the pain being specially referred to some intermediate spot —
injection of opium subcutaneously at that part should give decidedly
more relief than the same dose at a distance, it would afford ground
for believing that the cause of the neuralgia was localized in that
spot. In the ordinary way of rubbing sedative liniments on the
i cutaneous surface covering the seat of pain, we have no means
whatever of proving a local action on the suffering nerve, but rather
the reverse. Foi", take the case of the sciatic, where pain is acutely
' felt at the back of the thigh, and notably between the ischiatic
tuberosity and the great trochanter : if this be relieved by sedative
applications to the covering tegument, we are sure that the chief
action of the remedy must be on cutaneous ramifications of the
gluteal, lesser sciatic, and branches of the external cutaneous and
other nerves on the front of the leg. These will convey impressions
to the spinal centre, not far from the part where the roots of the
I sciatic are implanted ; so that if the neuralgia were of central origin,
it is very conceivable that the morbid action might in this way be
j beneficially modified. But, considering the depth at which the sci-
I atic nerve lies from the surface, it seems quite impossible that the
aconite, chloroform, opium, &c., should penetrate so far through
1 skin, fat and fascia, and even large muscles. There exists some
'^evidence to show that any strong impression made on the nervous
centres (such as cauterizing the ear, galvanizing the columna nasi —
V. Duchenne's' work) through incident nerves may put a stop to
■ some neuralgias. This, if confirmed, would very much corroborate
the view above expressed.

' Traits Therapeut., par Trousseau et Pidoux, vol. i. p. 787.

44 GENERAL PATHOLOGY.

The pathological relations of neuralgia are, of course, very dif-
ferent according to the cause which gives rise to it. If, however,
we take the commonest kind — viz., that which arises from cold,
malaria, or debility — we must allow that it manifests a very close
affinity with non febrile rheumatism. Rheumatic and neuralgic
pains are frequently so very similar, that they are only to be dis-
tinguished by the action of remedies. Iodide of potassium cures
the rheumatic, quinine and iron the neuralgic; while often it occurs
that in the same case, after having begun with the former, we have
to finish with the latter. The beneficial action of muriate of ammo-
nia in neuralgia noticed by several recent observers can scarcely be
dissociated from its remarkable and positive remedial action in mus-
cular rheumatism. The interesting but obscure phenomenon of
rheumatic paralysis is closely similar to, if not identical with, the
paralysis or paresis of motor-nerves, which so often forms a part
■. of neuralgia. Catarrh is allied to neuralgia by the similarity of its
I causes, the diffused pains in various parts, the resemblance of its
' inflammatory actions to those sometimes accompanying and depend-
ing on neuralgia, and in a large number of cases by its "juvantia."
I If exhaustion aggravates a neuralgia, so does it also a catarrhal
,! flux; while rest and toning means have an opposite effect. The af-
i i finity between neuralgia and ague in malarious disorder is strikingly
1; apparent: the two disorders so evidently replace one another, that
there can be little doubt that the difference is only one of situation;
the sensory nerves being chiefly afiected in the former, the sym-
pathetic in the latter. The therapeutical effects of arsenic, iron,
and quinine in the two disorders rapprochent them not a little.
(XII.) It seems a well-ascertained fact that the nervous tissue,
^ both in the centres and in the peripheral extensions, becomes more
j excitable and mobile in proportion as its power becomes weaker.
The motor nerve is more readily thrown into action, though the im-
pulse it communicates is weak and cannot be long sustained. The
' sensory nerve is alive to the least impression, and becomes in certain
cases gifted with almost preternatural acuteness. The brain is
highly impressible, but incapable of any continuous effort; and
' headache is easily induced. Stimulants or tonics, which seem and
are highly necessary, are tolerated with difficulty. The vaso-motor
nerves rapidly alternate between a state of excitement, producing
' chills, and one of depression, giving rise to heat-flushes and per-
spirations. It is very probable that this difference in the vital state
/ of the nerves depends on some molecular change in their composition,
in consequence of defective nutrition; but no chemical research,
that I am aware of, has yet proved such to be the case. Buhl's
/ examinations go to show that a state of unconsciousness coincides

with a watery condition of brain, such as is apt to exist in anaemia.
' (XIII.) The tendency of nerve disorder to aggravation, or to
make its first onset at night, is a very noteworthy point. Attacks
of cholera and of choleraic diarrhoea, of epilepsy, asthma, and pare-

GENERAL PATHOLOGY. 45

sis, are very prone to ensue at night; while^ neuralgic, rheumatic,
and other kindred disorders, are almost universally aggravated at
that time. A talented but woefully hypersesthetic female with whom
I am acquainted, whose nervous disorder verges towards insanity,
has for some time been always much worse towards the close of each
day. In the malarioid remittent of children, the paroxysm is in-
I variably nocturnal. The copious nocturnal sweats of phthisis and
I of obscure aguish disorder seem to be referable to lowering of the
' power of the vaso-motor and other nerves during this period ; since we
find tonic, astringent, and strengthening means to have a preventive
effect. It is certain that malaria is most potent at night; and this
is probably owing to the circumstance that the system is then less
capable of resisting it. I believe a similar explanation applies to
all the above cases. The morbid causes remain the same, but the
nerve-power is feebler and less capable of withstanding them. It is
not always easy to say how much of the increased morbid action
may be owing to the state of sleep, or to the particular diurnal
period. I believe that sleep does increase the liability to some
affections, especially to sweating; but in most it is evident that this
is not the principal cause, as sleep is entirely banished by the dis-
order.
, Another period at which nerve disorders of all kinds are very apt
/ to be aggravated is the catamenial. This is well called the monthly
' sickness, for it is certainly a season of lowered general and nervous
/power; and it has repeatedly occurred to me to find improvement
, which was previously going on smoothly interrupted by this some-
I what troublesome interlude.

(XIV.) It is impossible, in a work of this kind, not to take some
notice of the theory which Dr. Radcliffe has espoused, and to the
illustration and establishment of which he has devoted so much la-
bour and skill. His general position, as conveyed in his own con-
clusions {vide Lectures, Coll. of Phys., 1863, Lancet), is (1) that
living muscle, when left to itself, is kept in a state of relaxation
by the action of the natural electricity of the muscle; (2) that mus-
cle passes out of the state of relaxation into that of contraction,
when the attractive force which is inherent in the physical consti-
tution of the muscular molecules is no longer antagonized by the
action of the natural electricity of the muscle; (3) that the natural
electricity which antagonizes contraction is extinguished for the
moment by the instantaneous electrical currents of high tension
i (analogous to the discharge of the torpedo) which are developed
when muscle or motor nerve passes from the state of inaction into
that of action, and that, ordinarily, muscular contraction is brought
( about in this way ; (4) that the natural electricity which antagonizes
/ contraction is extinguished permanently at a certain time after
death, and that the permanent contraction of rigor mortis is brought
about in this way. Further on, he states that he believes that the
same conclusions are necessary with respect to the action of a motor

46 GENERAL PATHOLOGY.

sentient nerve in sensation, as those which are necessary with re-
spect to the action of a motor nerve in the production of muscular
contraction. Radcliffe proposes to substitute these views for the
doctrine that contractility is a special vital endowment of muscles
and sensibility of sentient nerves, which on the application of stim-
uli are aroused into functional activity. He applies his views to
explain the pathology of convulsions, spasms, tremor, and pain —
and concludes that all depend on vital exhaustion, and not on vital
stimulation. It is impossible for me to attempt here any critical
examination of the scientific experimental evidence which RadcliiFe
so copiously adduces. I can only consider how far his main views
are accordant with familiar and established facts, which cannot be
left out of sight. The gist of his theory seems to be, that alike in
health and in disease, muscular action as produced through the
nervous system, and sensation, are the results, not of increased, but
of diminished vital action. It appears to me, first, that he does not
suiEciently distinguish between the nutritive process which main-
tains the structure and vital properties of the tissues, and the func-
tional action in which these properties (as we regard them) are
brought into play. The former is, of course, directly. conservative,
and can only tend to increase the vital powers of the part; the lat-
ter is, from one point of view, wasteful, expending those properties
which are generated by nutrition. It is, therefore, very conceiv-
able that certain electrical currents and other phenomena should be
interrupted during the period of a muscle's action, which go on
steadily while it is at rest. Again, the common fact that muscles
well exercised by their motor nerves gain in size and strength, while
the reverse is the case when they are either unused or their motor
nerves are paralyzed, seems very subversive of the theory. If mus-
cular contraction implies diminished vital action of both muscle and
nerve, how can it be that the frequent repetition of such weakening
acts produces development and increase of vital force ? How can
death cause life ? Again, it seems impossible to admit that a steady,
sustained effort of voluntary contraction can be at all fairly classed
with a clonic spasm of convulsive disorder, however violent. True,
there are muscular contractions in both cases ; but in all other
respects they differ widely. The kind of contraction is different :
in one it is brief, violent, but unsustained; in the other, uniform, and
steady. The state of the brain is very different: in one, active,
conscious, with its functions of sensation and volition in full play,
and its vessels traversed by full streams of arterial blood; in the
other, the functions of sensation and volition in abeyance, and the
vessels anaemic or filled with dark blood. The respiration and cir-
culation in the convulsive attack are deranged from their healthy
state. The fact that a very powerful emotion will sometimes animate
even weak muscles to perform feats of extraordinary strength, seems
capable of no other interpretation than that a higher amount of nerv-
ous energy than usual is excited in the centres, and put forth through
0

GENERAL PATHOLOGY. 47

the nerves. The force so exerted is surely far greater than anj
which could be developed in the rigor mortis, which is all that the
muscle on Radcliffe's view can claim as its own. It seems, also, that
Radcliffe makes no distinction between pain the result of some
morbid action in a nerve or nervous centre, and a natural sensation :
both he regards as the results of diminished vital action. This
again seems quite erroneous. The morbid sensation is, as already
shown, often associated with numbness, motor paralysis, and other
signs of depressed vital power. But this is not the case with
healthy sensation, which, indeed, requires for its perfection a state
of active circulation in the sentient surface, as well as an active^
condition of the sensorium. Inflammatory pain is certainly of a
different nature to neuralgia; it is intimately connected with active
hypersemia of the affected part, and is unquestionably much more
likely to be relieved by depletion and cold than by any stimulation.
Certainly, no man would treat it in the same way as the pain of
anasmia or brow ague. In the close of his lectures Radcliffe states
that the pathology of pain agrees in all essential particulars with
the pathology of tremor, convulsion, and spasm ; and that the pro-
cess on which it depends implies vital exhaustion, and not vital
stimulation. He advocates the treatment of all these disorders by
supplying the weak nervous system with appropriate nutrients, such
as oily articles of food and medicine, with phosphorus in various
forms, by upholding and arousing the vital powers in general, and
the nerve power in particular, by a stimulant plan of treatment, in
which alcoholic drinks, ether, and phosphorus, in suitable doses,
figure most conspicuously. The use of sedatives, as opium or bella-.
donna, he discountenances. This quotation must, we think, con-
vince any experienced man that Radcliffe's view is far too partial,
and is by no means applicable to all the forms of sensation, healthy
and morbid. The pain-relieving efficacy of opium, belladonna, and
aconite, is as well established as any medical fact that we possess.
That the morbid states he refers to are very often dependent on
depressed vital action, there is no doubt; and we really are not
aware that any one maintains the contrary. But to endeavour to
prove that all phenomena involving motion and sensation, physiolog-
ical and pathological, are of the same kind, seems to us contra-
dictory to familiar facts, and we cannot consent to take any such
principle for the basis of our practice. If prolonged experience
convinces us more and more of any one thing, it is of the utter
diversity and radical dissimilarity of many pathological states and
symptoms called by the same name and outwardly seeming much
alike. It is the fashion of the day to try to refer all disease to
diminished vital action, and to assume (I think very unfairly) that
previous authorities have always referred it to increased. It would
be more correct to say that disease has been ascribed to deranged
or perverted vital action which may be increased or diminished.
Beyond this I believe w^e have not advanced yet.

48 CEREBRAL ANEMIA.

CHAPTE R III.

CEREBRAL ANiEMIA.

As one of the simplest morbid states of the brain, we may take
angemia, which properly implies a simple decrease in the amount of
arterial blood passing through the organ in a given time. The
observations of Kussmaul and Tenner on six male adults, backed by
those which they made on rabbits, show very conclusively what are
the results of this state when it is speedily induced. When both
carotids were compressed in the human subject, the vertebrals of
course remaining open, the principal phenomena were, pallor of the
face ; loss of consciousness ; dilatation of the pupils ; slow, deep, and
as.it were sighing respiration; and, in two cases of weak intellect,
a choking sensation, followed by vomiting and general convulsions,
which disappeared in a few seconds after the compression was re-
moved. Ligature of the common carotids, one or both in succession,
may produce no symptoms, or may cause paralysis and convulsions ;
the convulsions aflfecting the same, and the paralysis the opposite
side. The paralysis may precede, accompany, or follow the con-
vulsions. The eye of the operated side sometimes becomes blind-
Other symptoms which have been observed are, " dizziness, stupe-
faction, insensibility, loss of consciousness, of speech, and of free
play of the muscles in general ; difficulty in swallowing, nausea,
vomiting, swooning, and coma." The authors whom we are quoting
proceed to state that post-mortem examination traces the cause of
the paralysis to anaemia and softening of the corresponding cerebral
hemisphere, to a greater or less extent. They are satisfied that
" epileptic convulsions only manifest themselves in man, when,
together with the cerebrum, some or all of the parts of the encephalic
mass lying behind the thalami optici are suddenly deprived of blood
to a sufficient amount, but that sudden falling down, announcing the
approach of an apoplectic attack (?), unconsciousness, and insensi-
bility, originate in causes proceeding from the brain proper." The
affection termed by Trousseau, " congestion cerebrale apoplecti-
forme," in which he believes there is no congestion at all, but that
the disorder is rather allied to epilepsy or syncope, seems to be
essentially of anaemic character. A man falls down suddenly, as
if stricken by apoplexy ; is taken up in a state of stupor, and for a
quarter of an hour, or even longer, remains more or less in the same
condition — his intelligence confused, and his gait uncertain. The
following day he is quite well. In slighter cases, the patient is

CEREBRAL ANEMIA. 49

attacked, all at once, with giddiness ; loses sight and speech, and
staggers, sometimes falling down, but getting up again immediately.
In three or four minutes he is quite recovered. In these cases, as
in ordinary epilepsy, the face is pale at the commencement of the
attack, and only becomes flushed afterwards. It is a curious circum-
stance, which was observed in the compression of the carotid experi-
ments above quoted, that on the removal of the pressure, the face
became suffused. Indeed, Kussmaul and Tenner state, as a general
result of their observations, that releasing the ligature from the
cervical'arteries always produces temporary hypersemia of the brain.
Profuse hemorrhage after delivery, says Dr. Gooch, will cause the
woman to have a distressing headache, with throbbing in the head,

^ noises in the ears, a colourless complexion, and a quick, weak, often
thrilling pulse ; all which symptoms are greatly increased by any
exertion. Abercrombie^ describes how children may lie, for a day

' or two, in a state of stupor closely resembling coma from organic
disease — insensible, with dilated pupils, eyes open and insensible, the
face pale and the pulse feeble, and yet recover under the use of
wine and nourishment. This state is induced by causes of gradual
exhaustion, going on for a considerable time. It may occur in
adults, though less frequently than in children. " It differs from
mere exhaustion in the complete abolition of sense and motion, while
the pulse can be felt distinctly, and is in some cases of tolerable
strength." A case is related where deafness was induced by the
erect posture, and hearing immediately returned in the recumbent.
The patient was in a state of extreme weakness and emaciation. A
weakly female, aged 22, under my care, convalescent from catarrh,
stated that her head ached, and she became giddy and fell, when
she threw her head upwards and backwards. Comparing syncope
with apoplexy, Abercrombie says,^ " It is preceded by giddiness,
tinnitus aurium, and impaired vision ; and is accompanied by blind-
ness, dilated pupil, perfect insensibility, and not unfrequently passes
into convulsion." (The Italics are my own.) Kussmaul and Ten-
ner state that convulsions from hemorrhage do not ensue — (I) when
the hemorrhage is slow ; (2) when the animals are very much de-
bilitated ; (3) when the nutrition of the spinal cord has suffered;
(4) when large pieces of the excitable districts of the brain have been
removed ; (5) in animals subjected to etherization ; (6) doubtless,
when the excitable districts of the brain have undergone certain

• pathological alterations. The first and second clauses afford a rea-
sonable explanation of the non-occurrence of convulsions in many
cases of cerebral anaemia. Gooch's own personal experience, as
he describes it, illustrates well the chief effects of cerebral anaemia
in a chronic form. He says, any one who, from long defect in the
organs of nutrition, is reduced so that he has neither flesh on his
body nor blood in his veins, well knows what it is to lay down his

f On the Brain, p. 309. 2 Ibid., p. 300.

50 CEREBRAL ANEMIA.

head and doze away half the day without any congestion or inflam-
mation of the brain. It is clear that in most cases, in all except
those where cerebral anaemia is suddenly induced during a state of
health, the condition will not be one of pure diminution of blood-
supply, but of diminished and altered blood-supply. The system
will be not only ansemic, but spansemic. Further, this state cannot
exist for any length of time without modifying injuriously the nutri-
tion of the brain, and rendering it more excitable and weak, accor-
ding to the general law which we see so constantly exemplified.
This altered vital quality of the great nervous centres may exercise
a considerable influence on the subsequent phenomena, as has
already been shown by the above- quoted statements of Kussmaul
and Tenner. It is a most important fact observed by these excel- f
lent inquirers, that arrest of the blood-supply to a muscle, and the /
nervous apparatus with which it is connected, produces at first
spasmodic contraction, followed after a time by complete paralysis.
This is true in the case of the iris and the sphincter ani, and, no
doubt, holds good with regard to the other muscles of the body.
" Suddenly withheld nutrition" causes a sudden commotion, and
molecular change in the dynamic matter, which acts in the same
way as a stimulus on the nerves. The effect of slowly-impaired nu-
trition, as just observed, is somewhat similar : it renders the nervous
apparatus much more mobile than natural. On the other hand,
good and full nutrition renders the nervous tissue much more calm
and steady in its actings.

We may now proceed to gather up into some general conclusions
the chief results of the preceding discursive review. (1) It appears
that anaemia of the previously healthy brain, when speedily induced,
abolishes its functions and those of the chief organs of special sense.
(2) When slowly induced, and associated with spansemia, it pro-
duces eff"ects similar in kind, but less in degree, except in some ex-
treme cases. (3) Ansemia of the cerebral hemispheres, even occur-
ring suddenly, will probably produce unconsciousness, but not
convulsions. This may be regarded as the pathological condition
giving rise to the minor forms of epilepsy, the " congestion apoplec-
tiforme cerebrale," and certain forms of vertigo. (4) The true
complete epileptic paroxysm probably requires for its production
an at least tolerably active and excitable state of the brain-tissue,
and a suddenly induced anaemia, involving not only the hemispheres,
but the medulla oblongata, or at least the pons Varolii and tubercula
quadrigemina. (5) Venous hypersemia is well known to be equiv-
alent in its influence on nutrition to anaemia. It may give rise to
convulsion when it is rapidly induced in the brain, or to mere sopor
when it occurs gradually. Of the first we have an example in some
severe attacks of hooping-cough, and in apnoea. Of the second,
the following instance came under my own observation. A male,
set. 60, was under Dr. Sibson's care in St. Mary's with an aneurism
of the aorta, pressing upwards towards the right, and bearing upon

CEREBRAL ANEMIA. 51

the left brachio- cephalic and superior cava veins. His face, as well
as the neck and upper part of the chest, was swollen, and of a deep
dusky tint from venous congestion. The appearance was very
much as if his skin had been darkened by nitrate of silver. The
breathing was quiet, 17 ; pulse 96, open, soft, and equal in both
wrists. The cerebral functions were much impaired. The patient
remained constantly in a soporous state, very similar to that of the
patients described by Abercrombie. There were no convulsions.

The following cases, though not simple instances of cerebral
anemia, are, I think, very illustrative of that state, and altogether
are of considerable interest .* —

No. 1. — H. B , 38t. 31j female, seen in consultation with Dr. Palmer, Jan.
14th. — For about seventeen years has led a very dissolute life, drinking at
interval.'? large quantities of brandy and port wine. After these bouts she
would remain sober for a time. Had jaundice and swelled ankles in Scot-
land two or three years ago. No indications of syphilis. Her general con-
dition five or six weeks before I saw her Dr. Palmer describes as sufficiently
startling There was general oedema from the forehead to the toes, a pasty
wax-like complexion, complete anorexia and almost hourly tenesmus, with
pain in micturition. The motions consisted almost solely of jelly-like mucus.
There was marked tenderness on pressure all over the liver, but nowhere
else in the abdomen. Frequent vomiting. Urine cloudy, and usually de-
positing red or pale lithates : it was examined again and again, but no albu-
men was detected. Complains of severe pains across the under parts of the
roots of the toes, like those of atonic gout : has pains also in the legs and
insteps. Mental faculties blunted and dull. Pulse about 100. Amenor-
rhoea for three months. Under treatment she improved ; the cedema almost
disappeared, the skin generally began to look natural, but still she was very
weak in mind and body. She could eat a little meat, and slept fairly.
After having gone out and taken supper one evening, the symptoms recurred,
attended with smart bronchitis of right lung. This subsided under treat-
ment; but she remained in a feeble, semi-somnolent state, with frequent
sickness and anorexia — Feb. 5th. Some appearance of peritonitis, no somno-
lence, purged freely. — 9th. Several epileptic fits occurred yesterday and to-
day ; is incoherent, scarcely knowing her mother, and using bad language.
— 14th. Up to this date, incoherent, somnolent, talking, or screaming,
with occasional periods of partial consciousness ; sometimes clutches eagerly
at food, and eats a little ravenously. Sphincters do not act. Died same
evening. My impression, when I first saw this case, was very decided that
it was one of renal degeneration, with urasmic poisoning. The urine, how-
ever, was unlike any that is usually passed in such states. I examined it
carefully on Jan. 14 th and Feb. 5th : on neither occasion could I discover
in it anything manifestly morbid, except that the last specimen deposited
numerous nuclear corpuscles, which appeared to be those of renal epithelium.
It was full-coloured, sp. gr. 1017 to 1012, thick, with amorphous lithates,
and contained no casts or albumen. As to the amount passed, it was
below the normal, but was not very scanty. At the post-mortem, we found
evidences of slight recent peritonitis. The spleen was large, very dark,
and contained several small fibrinous masses. The liver was enlarged, and
in an extreme state of fatty degeneration, but free from cirrhosis. The
kidneys were very flabby and lax, but not apparently wasted j their surface

52 CEREBRAL ANEMIA.

was quite smooth. The matrix appeared thickened, the Malpig tufts nor-
mal ; the epithelium seemed to have accumulated in the tubes in excessive
quantity, but its particles were stunted and ill-formed. On the whole, it
could not be said that the kidneys were at all incapable of functioning.
The supra-renal capsules were carefully searched for, on both sides, but no
trace of them could be found. There was much fat both within and upon
the abdomen ; no bronzing of the skin : head not examined. This case goes
quite to corroborate Traub's view,^ who ascribes uraemia phenomena to
cerebral oedema and anaemia. Although the kidneys and their secretion
were by no means perfectly normal, yet they were, I think, sufficiently so
to make it pretty certain that the somnolence, delirium, and convulsions
were not the result of poisoned blood. The nutrition of the cerebral centres
was evidently seriously impaired for some weeks before death. The cause
of the anaemia is obscare^ I am scarcely inclined to attribute it to atrophy
of the supra-renal capsules, since these organs may be removed from animals
without any bad effects ensuing. Moreover, simple atrophy might affect
the system very differently to the usual atheromatous degeneration. It
seems most probable that the anaemia, the supra-renal atrophy, and the
degeneration of the liver, were coincident results of some general cause —
perhaps of the intemperate habits.

No. 2. — A. B., set. 46; March 28th. — A rather strongly-made man, of
medium height, not at all anaemic, rather the reverse; hair gray. Has
usually led an active life, much in the open air. Ill for fifteen months, had
at first an attack of painful griping diarrhoea, with some rheumatism ; this
was followed by loss or impairment of speech, so that he could not express
what he wanted. In a few hours, with the aid of a glass of gin, he reco-
vered. Subsequently, during the same journey in Australia, he was unable
to get off his horse from stiffness and weakness in the left limbs. A week
afterwards, his mouth was drawn aside a little. Two or three months later,
having been quite v/ell in the interval, he had a severe attack ; for three
weeks he was quite delirious, and was under medical care three months.
He lost all his memory; was heavy and dull; but after a seton had been
put in his neck, he became quite lively. He wears the seton still. He
could not walk from giddiness at one time, nor use his right arm. Now he
can walk, and has tolerably good use of the arm. He used also to have
pain, and a sense of heaviness in the head, as well as a feeling of pins and
needles in the legs; but these symptoms are much diminished. Pupils are
now equal and natural. Speech slow, intellect does not seem vigorous,
memory in particular is impaired. Right hand is unsteady; he cannot use
it to write. No disease of the thoracic or abdominal viscera. Urine highly
acid; deposits lithates. — April 10th. Seton removed; skin cool; head fairly
cool; pulse weak and quick. — April 16th. Head seems too warm ; its circu-
lation tends to be over-active. He says, however, that he has less pain in the
head than he had a week ago, and that he can now stoop and move his head
better without feeling giddy — 21st. Can write since his fore-arm has been
faradized; not, however, as freely as he used; but this seems to be from a
defect in his mental actions, rather than from any want of manipulative
power. He finds he misspells words, and uses wrong ones, or cannot recol-
lect the right. In speech he seems to have the same defect ; is slow in

' Schmidt's Jahrb., vol. cxiv. p. 308.

CEREBRAL ANEMIA. 53

expressing himself, and does not recollect or comprehend as readily or quickly
as he might. But he walks about well, goes long distances, and manages
all his matters. Is remarkably active in mornings. — 30th. Was at the
Crystal Palace the day before yesterday ; was fairly well last night, but had
pain in head all night ; and this morning when he got up, he felt ill and
weak. His mental power was much impaired, he could not find his way,
dropped his gloves and handkerchief, lighted a paint-brush instead of a
match, &c. I found him with cold skin and feet, head cool, lips pale, bowels
open, no appetite, pain still in head, but no tenderness ; pupils natural. A
dose of ammonia et spt. aeth. s. co. did not rally him. He had a hot
mustard bath to feet and hands, was put to bed, and took hot brandy-and-
water; after which he was better. He slept all the day, ate a tolerable
dinner, and by the evening was free from pain in the head, and had regained
his consciousness. — May od. Last night as he was going to bed, he suddenly
became unable to see to read, and felt giddy. This passed oflF by the next
day. His right hand has got more steady since the faradization, he can
shave himself. — June 10th. He has had two or three small attacks since last
report, always directly traceable to over-exertion and subsiding with rest
and a little stimulus. In these his hands are cold, his pulse weak, he stag-
gers, and his brain evidently fails to function properly. — 9th. Yesterday, he
went to the Zoological Gardens, having been to the Crystal Palace the day
before ; he remained well until dinner-time, when he seemed stupefied, and
was unable to feed himself properly. When brought home, he was cold,
with a feeble pulse, and could only mutter inarticulately. In the morning
he was much the same, quite speechless. After hot coffee and brandy-and-
water, his pulse rallied, and became full but soft, and his head hotter than
before. About two hours after, finding him still unable to speak, and with
an active circulation, I bled him to 14 ounces ; he bore it very well, but
did not improve materially. He got out of bed himself some hours later,
and walked down two flights of stairs. — 13th. Yesterday he continued in
nearly the same state j but to-day at 11 A. M., he had a severe epileptic
paroxysm, and another at 4 P. M. After the first, he had liq. opii sed.
n\^xv, but did not sleep. The convulsions affected both sides, the right es-
pecially; they lasted fifteen to twenty minutes. During their continuance,
the face and neck were congested, and covered with sweat ; the eyelids were
constantly opened and shut ; the respiration at one time was embarrassed.
The second paroxysm ceased when I raised his head to put a seton in the
neck. — 16th. Since the last report, he has had very numerous epileptic
paroxysms, many of them very severe, and the intervals sometimes shorter
than the attacks. He is quite unconscious; urine is passed in bed; body
bathed in sweat. In evening of the 14th, he began to take morphia by Dr.
Sieveking's advice, who saw him with me, and I administered chloroform
by inhalation. By noon of 16th he had taken about six grains; the pupils
were contracted, the pulse good, 96, and the epileptic attacks had ceased
for twelve hours. — 18th. Remains still unconscious; no convulsions; he
continued to sink all day, and died at 6 A. M. of 19th. During the last
twenty-four hours, the right arm was evidently paralyzed. — P. M., twenty-
eight hours after death. Scalp pale, cerebrum very pale. Arachnoid of
surface white-spotted, lifted up by clear fluid which was abundant everywhere.
The gray matter was everywhere very pale. The vessels appeared fairly
healthy; there was no trace of emboli. All the parts, cerebellum, meso-
cephale, medulla oblongata, and cerebrum, were carefully examined; but to

54 CEREBRAL ANEMIA.

the naked eye there was no evidence of morbid change in any of them; only
the roof of the ventricles was, perhaps, abnormally firm. Careful microscopic
examination was made of the thalami optici, and corpora striata, as well as of
the cerebrum, cerebellum, and medulla oblongata; but the only change that
was detected was the deposition of orange-coloured pigment masses, along
the vessels of the two cerebral ganglia, there was nothing else that could
be pronounced certainly abnormal. In the fornix, however, the fibres seemed
to be in great measure disintegrated. No exudation corpuscles were found
anywhere. The heart was very flabby indeed, but the muscular tissue of
the left ventricle was fairly healthy. Kidneys very flabby, but not diseased.
Remarks. — The primary disorder in this instance is, unfortunately, obscure.
All that can be affirmed is that it left no unequivocal traces of organic change,
and yet it impaired and weakened the functional power of the brain It
may have been an attack of congestion, or, what I rather incline to, an af-
fection of the nature of sunstroke. There seems no doubt that the seton for
some time was highly beneficial, but its removal was not apparently injurious.
Some strychnia, which was given on two occasions, did not seem to have
much effect, although it caused once spasmodic twitchings. The patient was
of a very active disposition, and greatly disregarded my repeated admonitions
to keep himself more quiet. The enfeebled state of his nervous power was
clearly shown by the frequent recurrence of failure of cerebral function,
generally in connection with over-exertion. The circulation was always
depressed at these times; but this seemed to be secondary, and there was
no indication of ordinary syncope. It appeared as if muscular exertion con-
sumed the nervous force, and left the cerebral centres enfeebled. The last
attack clearly was produced in this way. In this it was evident that it was
not only depression of the circulation which caused the failure of cerebral
power, but that the paresis of the latter, to some extent at least, was primary.
This may be fairly inferred from the circulation having become vigorous
without the restoration of the cerebral functions. The venesection had no
immediate effect, either for good or bad; but there is too much reason for
suspecting that it may have been concerned in inducing the convulsions
which came on three days later, and caused death by asthenia. The results
of the dissection, taken together with the history of the symptoms, incline
me much to believe that the impairment of function proceeded rather from
dynamic than from an organic defect, and that under more favourable cir-
cumstances, nearly complete recovery might have been attained. Admitting
— which is, I think, probable — that some amount of organic lesion had
occurred, it seems from the history of the disorder that this was rather
general than local, and probably it affected chiefly the gray matter of the
convolutions. The anaemic condition of the brain after death certainly cor-
responds very well with the symptoms which occurred during the last few
days of life; and the supposition seems very probable that during the previous
less severe attacks the condition of the brain was similar, especially as during
these attacks the general circulation was evidently much depressed. How this
failure of circulation was brought about is not at first sight clear; most pro-
bably it is to be ascribed to the close commissural connection existing between
the cardiac centres in the cord and the superior encephalic. We know that
a sudden shock to the brain will powerfully depress the heart's action; and
we may conceive that the central collapse would have the same effect in this
case. On the other hand the slackening of the circulation would, of course,
considerably increase the primary cerebral paresis. The sub-arachnoid effu-

CEREBRAL ANEMIA. 65

sion was, I believe, the result of the paresis of the brain, whose nutrition
was no longer adequately carried on, and so there ensued a kind of passive
exudation from the bloodvessels to fill the space of the shrinking organ.
The fatal convulsions resulted, no doubt, from the increasing debility, and
anaemia of the eiJtephalon having produced, according to the general law,
V. p., a state of hyper^esthesia of the excitable districts, the mesocephale,
&c., which displayed itself in this manner. They were too prolonged, and
recurred too frequently to have depended on mere spasm of the carotids
and vertebrals, though this may have occurred at intervals, and had some
share in the phenomena. Kussmaul and Tenner state that the brains of
rabbits could not be deprived of blood more than two minutes without death
actually ensuing. On the whole, I regard the case as one in which, owing
to some unknown influence, such as sunstroke, the functional power of the
brain had become much impaired, and was left in a condition liable to be
still further de.pressed by slight causes.

The morbid changes induced by cerebral angemia, in so far as they
are demonstrable, are such as might have been anticipated. The
insuflBciently nourished tissue falls into a state of decay, termed
"white softening." This occurs in the human subject in about five
days, or rather sooner, according to the reports which are given of
the operation of ligaturing the carotid. It is no uncommon thing
to find in connection with an angemic state of the brain after death
an excessive amount of interstitial and sub-arachnoid fluid. This is
secreted to take the place of the more or less shrunken cerebral
mass, and is poured out all the more readily in consequence of the
loss of tone in the coats of the vessels. According to Buhl's re-
searches, this condition of a "wet brain" coincides with a tendency
to stupor. In cases of softening, affecting part only of one hemi-
sphere, resulting from embolism of an artery, it is affirmed by Panum'
that the appearance of the softened part depends on the time at which
it is examined after the deprivation of blood. Red softening com-
mences in twenty-four or forty-eight hours, and lasts from eight to
fourteen days : it is succeeded by yellow softening, and this again,
after several months have elapsed, by white. The cerebral tissue
in the affected part becomes gradually softened and more disinte-
grated, and paler in colour, as time elapses. In red softening there
is always increased tension and injection of the collateral vessels.
The colour is produced not only by vascular injection, but by capil-
lary extravasations. Subsequent changes consist in fatty degene-
ration of the tissues and decolorization of the blood-globules.

The diagnosis of cerebral anaemia is evidently a point of the highest
importance, and one which may by no means be always easy. When
the face is pale, the scalp cool, the eyes uninjected, the general
circulation quiet — when there is no appearance of cerebral excite-
ment, but rather of failing power — when the recumbent position
affords relief, and the distressing sensations in the head are described

* V. Meissner's Report in Schmidt's Jahrb., vol. cxvii., p. 209.

56 CEREBRAL ANEMIA.

as a weight at the vertex, or a feeling of opening and shutting, and
as if the top of the head Avere being lifted off — the nature of the case
is clear. But there may be conditions of the most marked general
angemia or spangemia, in which, of course, the cerebral circulation
participates, and yet in which there may arise temporarily a state
of cerebral hypersemia. By this I mean that though the blood is
evidently of very imperfect quality, deficient in solids and in red
cells, yet that an excess of this blood is sent to the brain above what
it ought under the circumstances to receive. Nothing is more com-
mon than to find anaemic patients complaining of headache from the
administration of necessary tonics, because their nervous centres
have been brought into such a state of hypersesthesia by the impaired
nutrition that they can hardly tolerate anything of a stimulant nature.
A little excess, therefore, even of spansemic blood, may cause distress
to a- feeble brain, which after it has regained more healthy tone, will
bear and be benefited by a larger amount of much better blood.
The case is similar to that of the starved man, whose very preserva-
tion depends on his being fed most sparingly for some time. The fol-
lowing case is of interest both as regards diagnosis and treatment : —

No. 3. — J. W., set. 31, smith, admitted August 4, 1862 — Is in a state
of the most extreme anaemia from rectal hemorrhage, which commenced nine
years ago, and has recurred at intervals ever since. Latterly it has been
constant ; he bleeds whenever he has a motion, and even sometimes when
he urinates. Has lost as much as a pint at once. His head throbs; he has
pain at the precordia, palpitation and giddiness in walking. Bowels usually
loose. A hruit de diahle is heard on both sides of the neck, very loud whea
he turns his head to the opposite side, feebly when he holds it straight.
Skin cool; pulse feeble. No piles could be discovered. On examination,
the mucous membrane was pale and rather relaxed. Ordered lead and
opium pills ter die, with castor oil and sulphur o. n. — 7th. No bleeding,
or very little, since. Became unconscious to-day about noon, and is now
(7 P. M.) quite so; he lies with his head low, thrust down into the pillow,
turns away from me, and struggles pretty strongly if I attempt to turn him ;
perspires a good deal, and is rather hot; pupils dilated, pulse over 100, and
rather forcible; some stomach disturbance to-day. His condition was rather
one of soporose delirium than of coma. Opium was ordered, tt\^x1 of tr. opii
stafhn, and it^xx o. h., until he appeared to sleep; but he would not take
it, kept bis mouth firmly closed, and at 12 midnight I found him very rest-
less, thrusting his head repeatedly into the pillow, and quite unconscious.
Tr. opii TTLxl 2 dis horis in enemate. — 8th, 10 A. M. Is in much the same
state; has had two or three enemata, works much with his head against the
pillow, has not spoken or given any sign of consciousness. Blister to neck.
— 6 P. M. Is now cool. Pulse quieter, smaller, feebler. Has become
more conscious, and has spoken, but is still wild and restless, throwing him-
self about; looks deathly pale. Has taken a good deal of milk and egg with
brandy, and small doses of tr. opii. — 9th, 10 A. M Is still very restless,
and perfectly pale, but quite sensible, with a cool skin and a medium-sized
pupil; some little bleeding this morning. — 10th. A large protrusion of
inflamed piles, partly mucous and partly cutaneous, was shown me to-day.

CEREBRAL ANEMIA. 57

The skin was divided, and the mucous portion tied with ligatures in two
separate masses. Some blood that flowed I observed coagulated perfectly.
Tr. opii TTLxxx were given in brandy-and-water after the operation. He
says he did not know me till to-day. — 11th. Going on well ; has had seve-
ral hours' sleep; temp, of axilla 99°, of hand held out of bed 97° F. ; is
taking tannin and ol. morrh. — 15th. Doing well. P. c. oleo. Tr. ferri
mur. iTLxij ter die. — Sept. 1st. Quite convalescent, is getting stronger every
day, feels better than he has done for nine years, has lost the cardiac palpi-
tation and that in the neck. Pulse very much weaker and smaller than it
was during his illness. Bowels act well, no bleeding. Feb. 10th, 1863.
Has had no return of the bleeding; says he is a better man than ever he was.
Remarks. — This man has been long under treatment, which had quite
failed, because the source of the hemorrhage had never declared itself, as it
happened to do while he w^is under my observation. There was not the
least trace of piles when I first examined him, and I had no idea that any
would be found. The case is instructive in this point of view, as showing
how long concealed the cause of such serious hemorrhage may remain, and
how closely it behooves us to search after the '' causa mali." But this by the
way. The bearing of the case on our present subject is to illustrate how in
the extremest anaemia a state of relative hyperasmia may arise, and bring
the patient into serious peril. The brain in this man during his acute dis-
order was evidently seriously implicated, irritated, and over-excited. His
foi'cible struggling and resistance showed that it was no state of mere pas-
sive stupor from failure of nutrition. The open, forcible pulse, the increased
cardiac action, and the dilated pupil, as well as the heat of the surface, were
evidence to my mind that the cerebral arteries were dilated, and that the
weak and irritable brain was oppressed by an overflow of blood. There was
grave reason to fear that ventricular or subarachnoid efi'usion was imminent,
and that as this took place and the active congestion declined, fatal coma would
ensue. Opium was given, with the view of contracting the arteries, and so
by lessening the blood-flow of reducing the cerebral excitement. Though
not administered so regularly as I wished, it was yet given in sufficient
quantity to produce an eff"ect; and this certainly seems to have been benefi-
cial. The blister did not rise very fully, and had not, in my judgment,
much to do with the improvement. It was very remarkable how, as he be-
came convalescent, the pulse grew small and weak compared with what it
had been during the cerebral attack. This indicates the recovery of the
sympathetic system from the state of paresis into which it had been plunged
— V. p. It is a question of material importance to determine how far the
state of the skin of the head and face may be taken as an index to that of
the intra-cranial organs. One would think it a priori probable that the
external and internal carotid and their branches would be influenced simi-
larly by the nerves which supply their coats, and, therefore, that the state
of the circulation would be alike in both sets of vessels. To a great extent
I believe this is actually the case, though not invariably. It must be re-
membered that the brain is very much more vascular than the skin, and also
that it is supplied by two other arteries besides the internal carotid, which
receive vaso-motor nerves from a diff'erent source. It is, therefore, quite
conceivable that the brain might be receiving an excessive supply of blood,
although the vessels of the external tegument were but moderately filled.
Moreover, if there existed any tissue excitement of the brain, this would
create an attraction of blood to the internal viscus, which would tend to

58 CEREBRAL ANEMIA.

leave the external tegumeat in a minus state. However, I can speak from
personal experience to the coincidence of a cold state of the skin of the fore-
head, with overpowering drowsiness, i. e., cerebral anaemia, and to the con-
verse. I have met with patients who looked at first sight most blooming,
but who complained that their cheeks were burning and their heads throb-
bing, and who wished, in fact, to be cured of their extra and intra-cranial
hypersemia. As a general rule, if the skin of the head is cool and pale, we
may conclude that the intra-cranial arteries are admitting but little blood;
but the converse, probably, has many exceptions. The state of the eye is,
perhaps, a more sure guide than that of the skin. A red, injected, eager
eye can scarcely imply anything else than an hyperaemic brain; and a pale,
dead, white languid eye almost certainly indicates the reverse. The state of
the urine may give valuable information. Pale, copious, low specific gravity
urine will surely coincide with an absence of, arterial hypersemia; while
scanty, red, lateritious, dense urine will invest the cerebral symptoms with an
opposite meaning. It is scarcely necessary to refer to the pulse, except to
that of the carotid. If this is open and bounding, it indicates that the arte-
ries are uncontracted, and admitting a full current of blood. Of course, the
reverse would not necessarily imply cerebral anaemia, any more than in peri-
tonitis the small, wiry pulse implies an absence of inflammation. Panting,
hurried, or irregular respiration (the lungs being healthy) would point
towards anaemia. The state of the pupil is so much controlled by that of the
brain, as also indeed by that of the cord,* that its indications are not reliably
definite. An excited brain or a depressed cord will produce a contracted
pupil, or vice versa; though in medium states I think a contracted pupil
generally coincides with contracted cerebral vessels, and a dilated with un-
contracted.

The treatment of anasmic states of the brain is sufficiently evident
if the anaemia be general; the only needful caution being '■'■ festinare
lente :'' that is to say, as fast as the weak and hypergesthetic nerv-
ous centre will permit. Good air and good nourishment, and suf-
ficient rest, are, of course, essential ; and for medicines, steel wine,
citrate of quinine and iron, carbonate of iron, and cod-liver oil, will
generally do good service. In cases where the digestive power is
feeble, the lactate of iron, or fer reduit, will probably be more easily
assimilated than the more common preparations. Rennet wine may
be recommended to promote the digestion of azotized food.

Where the anaemia is partial the object of treatment must be
either to stimulate the languid brain moderately, or to prevent and
allay arterial spasm. This subject will be considered under the
head of epilepsy.

For the following case I am indebted to the kindness of Dr. H. C.
Stewart, whose correct diagnosis deserves great praise : —

No. 4. — A general oflScer, aet. 60 years, who had been with our peninsular
army and at Waterloo, and subsequently with the army of Don Pedro in
Portugal, has had frequent attacks of intermittent fever, and during the
last twenty years has suflPered from spasmodic asthma. Dr. St. was sent for

' Dr. Fraser'a paper on Pbysostigma Venenos,, Edin. Med. Journ. July, 1863.

CEREBRAL ANEMIA. 69

in a great hurry, and found on arrival that his patient had lost all power over
the left side, and had very partial sensation. The muscles of the face on
the aflFected side were all relaxed, while those on the opposite side were rigid
and drawn. His tongue when protruded was also drawn to the opposite
side. He had great difficulty in swallowing his saliva, and his speech was
imperfect. His urine was constantly dribbling away from him. B. opened
three hours before this attack. There was considerable difficulty of breath-
ing. Consciousness was retained, and but for the difficulty of speaking he
would have answered questions correctly. Left pupil contracted, right mo-
bile. Pulse 100, weak and small. Skin hot and dry; thirst; tongue
coated thickly. On inquiry St. found that he had had similar attacks
before, for which he had been bled and mercurialized ; that he had also had
frequent attacks of intermittent fever, and spasmodic asthma. This in-
formation led him to believe that the prostration of the nervous power might
be dependent upon some miasmatic poison, particularly as he had recently
been staying near Woolwich. He gave therefore six grains of quinine, and
some warm drink. About forty-five minutes after St. learned that he had
had a very slight rigor, which was followed quickly by heat, and almost in-
stantaneously by profuse perspirations, while as the attack passed off the
symptoms of hemiplegia subsided. For a week afterwards the ague recurred
every other day, and with it the hemiplegia, but in a slighter degree. The
disorder yielded to quinine. Since then he has had one other attack in
every respect similar, but less severe Remarks — There can be little ques-
tion that the phenomena in this highly interesting case were produced by^
spasm of the cerebral arteries, which was so complete on one side as to
prevent the nervous centres from functioning. Such spasm of the arteries
is constantly present in the cold stage of ague to a greater or less extent,
and may be, as in a case I shall subsequently relate, sufficient to obliterate
the radial pulse. The symptoms produced by one-sided cerebral embolism
are very similar, but the record of the case makes it perfectly clear that no
morbid cause of this kind was in action. The paralysis of the sphincter
vesicae shows that the cord must have been affected to some extent, probably
in the same way as the brain. It is worth remarking that the facial nerve
was palsied on the same side as the limbs according to the usual^ but unex-
plained, event in all hemiplegia.

The following remarkable history is quoted by M. Bailly^ from
Wirtensons Memoirs on Opium: — ,

No. 5. — A lady of distinction was attacked at 11 P.M. with fever, attended
the next day with continual nausea, and vomiting of all food. After a small
dose of tartar emetic remedies were resorted to, to relieve the vomiting, and
with advantage. But the second night the fever returned at 11 P.M.,
and scarcely had the patient complained of feeling ill, when she lost the
power of speech and consciousness. Hoffman of Munster, who happened to
be at hand, was summoned. He found her speechless and in a kind of sopor,
her eyes open and fixed, her limbs stiff, as in catalepsy. Her pulse was
small and intermitted frequently, and her breathing was difficult. In short
she had a well-marked soporous intermittent fever. All who were present
feared that she would die speedily. In such cases eminent authorities advise
emetics, irritating enemata, or blisters, and stimulants, but Hoffmann, who

* Bailly — Traite de Fievres Intermittentes, p. 436.

60 CEREBRAL ANEMIA.

had no confidence in such measures, whose inutility he had often experienced,
followed a very different method. It was not the case to temporize, and in
order to save the patient it was urgent to have recourse to effectual means.
What remained then to be done? — try the administration of opium. But
how could one venture to counteract an unnatural sleep with a remedy
which causes sleep ? These considerations did not weigh with this physician
taught by experience. He poured into the patient's mouth ninety-five drops
of liquid laudanum, and he saw that she swallowed it. After the lapse of a
few minutes the pulse was developed, and the breathing more free, and in
less than half an hour the lethargy was dissipated, and the danger past.
The pulse was full, the limbs had regained their suppleness, the patient
regained consciousness and began to speak. Febrile heat succeeded, and
afterwards sweating concluded the paroxysm. The next day bark was
ordered to prevent the return of the disorder, but the stomach rejected it in
every form. Enemata of bark were ineffectual, for at the same hour the next
night the paroxysm returned and with the same alarming symptoms as before.
The laudanum was given again successfully. The next day the stomach was
still intolerant of bark, and a third fit was apprehended. On the suggestion
however of the husband, the laudanum was given one hour before the time
of recurrence ; it did not prevent the paroxysm, but it deprived it of the sopor
and the alarming symptoms. After it was over the patient was able to take
a vinous infusion of bark, and was soon cured. liemarks. — The correct
reading of this most interesting case is I think similar to that of the prece-
ding. The soporous symptoms came on at the onset of the paroxysm in the
cold stage, at the time when arterial spasm is prevalent. They were removed
and obviated by a powerful sedative, which we must presume to have acted
on the over-excited vaso-motor nerves, and to have thus quelled the spasm.
As the blood-flow returned to the encephalon its functions were restored.
Trotter's experience of the good effects of opium given at the commencement
of a paroxysm is quite in accordance with the above history. He found the
pulse, from being weak, quick, and sometimes irregular, become less frequent,
full, and equal ; an agreeable warmth was diffused over the whole frame, and
every unpleasant feeling vanished. This action of opium is analogous to
that which it exerts in cases of renal and hepatic calculus, and spasmodic
stricture of the urethra, where it seems to relax contracted muscular fibre.
I am well aware that it has been thought even more efficacious in the hot
stage of ague, and that it has actions apparently of a contrary kind. These
points will be hereafter noticed. It need scarcely be stated that the admin-
istration of opium would not be suitable to every kind of soporous inter-
mittent. If the coma depended on hyperaemic congestion it would be of
course contra-indicated, at least in a full dose. It may be remarked with
regard to the view I maintain as to the action of opium (v. remedies), that
there is nothing inconsistent with it in supposing that a stimulant may cause
relaxation of existing spasm, as in Dr. Salter's cases of asthmatic paroxysm
arrested by alcohol.

ANEMIA OF THE SPINAL CORD. 61

CHAPTER IV.

ANiEMIA OF THE SPINAL CORD.

We are chiefly indebted to Kussmaul and Tenner for any accurate
knowledge on this head. They tied both subclavian arteries close
to their origins in several rabbits so that the blood was conveyed to
their brains solely through the carotids. They then compressed the
arch of the aorta so that all afflux of arterial blood to the trunk of
the body was cut off. The results are described as follows. Respi-
ration becomes at once slower, and gradually in the direction from
back to front weaker and weaker. The hinder part of the body soon
becomes completely paralyzed, while the fore-legs are only partially
so. In most of the aftimals paralysis of the hinder part of the body
came. on without any convulsions. In three of them a short slight
trembling preceded ; whilst these trembling movements were in one
case only somewhat more rapid, resembling those occurring in para-
lysis tremulans, and lasting for some seconds. Within a few
seconds, or at most within from one to one and a half minutes the
paralysis of the hind legs was complete. Peculiar movements similar
to those witnessed in chorea are regularly observed in the fore-legs
some time after tying the arch of the aorta. It is not at first clear
whether these movements are voluntary, or are involuntary convul-
sions: the latter however is found to be the case. They are fre-
quently repeated, and are produced by a reflex act when the legs
are touched. They gradually cease as life becomes extinct. Respi-
ration ceased in from eight to eighty-one minutes after the last con-
stant compression. The heart stopped beating in from eight to
twenty minutes after the last breath. Consciousness appeared but
little disturbed up to the last moment. In one experiment the sub-
clavians were tied, and the aorta compressed, which produced almost
immediately complete paralysis of the hind and partial of the fore
legs. The carotids were now compressed, whereupon a violent epi-
leptic attack ensued within a few seconds, but ceased on removing
the compression from the carotids. This experiment puts in a clear
light the part which ansemia of the encephalon plays in producing
general convulsions, and shows that anaemia of the spinal cord is
marked more by paralysis than by convulsion.

Such being the results which experiment teaches us we may look
for when anaemia of the cord exists, we have now to inquire how far
we are likely to meet with this condition as an actual morbid change,
and how far we are to recognize anaemia of the cord as a vera causa

62 ANEMIA OF THE SPINAL CORD.

of disease. The mode in which the cord is supplied with arterial
blood, viz , by a succession of small arteries entering the vertebral
canal through the intervertebral foramina to anastomose with the
anterior and posterior spinal derived from the vertebral, makes it
less likely that it should be deprived of blood by constriction or ob-
struction of its vessels than is the case with the encephalon. It is
not very likely that a large number of small arteries would become
and remain constricted simultaneously, and if only a few remained
open they would supply blood to the tracts of capillaries. The
cases where it seems to us most probable that a paralysis may be
dependent on anaemia from arterial constriction are those where the
affection ensues paroxysmally apparently in connection with mala-
rious fever. Romberg relates a case of this kind where motor par-
aplegia occurred according to a tertian type, disappearing spon-
taneously. After the due administration of quinine the paralysis
ceased to return. M. Bailly describes how, during his stay at Rome,
when he was evidently under the influence of malarious infection,
he experienced every day about three or four P. M. an extraordinary
weakness of the legs, so that he could hardly get along, and was
obliged to use his arms, which were unaffected,* to pull himself by the
banisters up stairs. He was cured of this symptom by quinine.
The following case, for which I am indebted to my friend, Mr.
Moullin, was probably of the same kind: —

No. 6. — H., aet. 45, labourer, was seized July 9th while at work with
violent pain across the loins and with numbness running down the legs.
The urine was retained so that he could not pass it, and there was involun-
tary discharge of feces. When first seen he was lying on his back at full
length, the toes pointing straight out, the skin cold, the legs paralyzed and
insensible, even when pinched with the nail. He was quite unable to stir.
No pain or disorder elsewhere. Quite conscious. Ordered an enema of
turpentine with aloes, and calomel gr. v + pulv. jalap, co. gr. x. After
the enema and purge had acted freely the limbs still remained powerless ;
the pain continued, but was relieved by a croton-oil liniment. .July 11th.
Quin. disulph. gr. x ter die. The next day sensation returned, and the
next he could sit up in bed. In a week he walked to the dispensary, and
soon after was quite well. The record sufficiently proves that no organic
disease existed in this case, the suddenness of supervention and the speedy
recovery are quite unlike simple or direct paralysis of the cord, the non-suc-
cess of the purgatives and the good effect of quinine negative the existence of
inhibitory irritation, so that j)ar voie d' exclusion we are almost obliged to
refer it to anaemia from arterial spasm. I have before recorded a similar
case where hemiplegia ensued in a like way, and it does seem to me most
probable that such cases depend on arterial constriction, principally because
we have pretty certain evidence that at the commencement of an ague par-
oxysm the involuntary muscles as well as the voluntary are thrown into a
state of abnormal contraction.

These instances are, however, very rare, and we think they afford
no sufficient warrant for extending the same view of causation to all

HYPEREMIA OF THE BRAIN. 63

instances of so-called reflex paralysis. It is worth remarking that
general anemia suflficient to produce complete loss of vision does
not cause paralysis, v. Gooch's case of fatal flooding. The results
of the habitual use of ergotized grain as food are not very favour-
able to the view of permanent paralysis being occasioned by anaemia.
Dr. Brown-Sequard states indeed that ergot produces a contraction
of the bloodvessels of the spinal cord and of its membranes, and,
therefore, diminishes the amount of blood circulating in these organs.
If this be so, we should certainly, on the above view, expect to have
paralysis as a much more constant and early symptom than it ap-
pears to have been. It does not seem to have occurred in the earlier
period of the affection, but to have succeeded to severe spasms
aff"ecting the limbs, and producing even trismus and opisthotonos.
Violent convulsions and tetanus are produced by ergotism as well
as paraplegia. I have given tr. ergotge 5ss ter die for more than a
month in a case of proptosis, &c., without observing any efl"ect which
could be ascribed to anaemia of the cord. Of course, a relative
ansemia may be produced without materially impairing the functions
of the spinal centres. Just as the skin of the fingers retains much
of its sensibility, even when the supply of blood is much di-
minished, so it will be with the cord. On the whole, it appears to
me, that we have no suflficient grounds for regarding spinal anaemia
as a pathological state which we are likely often to meet with. It is
probable that in cases of paresis which we shall presently consider
more or less of anaemia may exist, but this is not the primary con-
dition, and does not rule the treatment.

In the treatment of any case of supposed spinal anaemia from
arterial spasm, the moderate inhalation of chloroform, friction with
stimulating liniments to the spine, the administration of quinine
with diff"usive stimulants and sedatives, and a prolonged warm bath
would probably be the most efficient remedies.

CHAPTER V.

HYPEREMIA OF THE BRAIN.

By this term we understand an increased flow of arterial blood
to the encephalon. This true hypersemia should be distinguished
from venous congestion, which is common enough in the closing
periods of various diseases, and at post-mortem examinations, but
is rarely the object of treatment, and in its action upon the brain
approaches much more to anasmia than to true hyperaemia. The
common varicose ulcers of the legs afford proof how unfit stagnating
venous blood is to nourish the integument, and it may well be imagined

64 HYPEREMIA OF THE BRAIN.

how much moi*e susceptible a tissue, of so high an order as the hrain,
will be of the deprivation of its proper nutrient and stimulant.
With venous hyperaemia we have here, therefore, nothing to do.
Of arterial we have first to remark that it may be either physio-
logical or pathological. The first, when it is subordinate to the
functional power of the nervous tissue, and ministers to its activity ;
the second, when it surpasses this limit, and becomes excessive.
To quote a sentence from the Manual of Patliology, p. 81 : " In
the one case it supplies a want, in the other it imposes a burden."
The very same amount of blood-supply may be either beneficial or
injurious, according to the vital quality and condition of the cerebral
structure. A weak and irritable organ will be oppressed by that
which only supplies the necessary pabulum to the more active life
of the stronger. When our brains are jaded and Aveary with work,
we find that we gain little by increasing their blood supply with
vinous stimulants, and that repose is essential to enable the organ
to regain its power. When, however, there is less exhaustion we
are familiar with the invigorating influence of wine on the mental
faculties.

Pure cerebral hypersemia, considered apart from primary cerebral
excitement, is by no means very common, at least in this country.
Theoretically, it requires for its production increased action of the
heart and relaxation of the contractile coats of the cerebral arteries.
It is mostly in certain malarious fevers that we find these conditions
existing. In a case of double quotidian paroxysm under my own
care the patient, a male, aged 46, became quite delirious in the
fever, "singing and quite out of his mind." The disease soon
yielded to quinine. Copland describes the symptoms of the period
of reaction as consisting of flushed face, tumid features, prominent,
red, and watery eyes, and pain of head attended by a feeling of
distension and throbbing, often passing into delirium. Ranald
Martin writes of the remittent fever of Bengal during the stage of
reaction : " The blood-current, previously oppressed, becomes now
hard and quick, ranging from 110 to 120 pulsations in the minute,
and the force and frequency of the circulation through the brain,
superadded to the already disturbed condition of the nervous func-
tions, give rise to confusion of ideas and loss of mental control,
amounting occasionally to actual delirium." Such is the hyperseraia
that he states his life was only preserved by a profuse hemorrhage
from the nose during the height of the first two paroxysms in a
severe attack of jungle fever he underwent. He cites from Dr.
Henderson a most proving history to show how powerfully the cere-
bral congestion, occurring during remittent fever, tends to issue in
apoplectic extravasation. So often did the one terminate in the
other that it was "hard to draw the line between them."

It is highly probable that in these fevers the hypersemia is both
greater and more injurious because of the impaired state of the nerv-
ous force in the brain which is depressed by the primary action of

HYPEREMIA OF THE BRAIN. 65

malaria, the original cause of the disease. Convulsions do not seem
to be a usual result of this cerebral congestion, neither of the authors
above quoted mention them. Bailly, however, seems to have observed
numerous instances at Rome of intermittent fever which he calls
"convulsive." The motor disorder showed itself, however, more as
tonic contraction than clonic, and there was no spasmodic closure of
the glottis. The following instance affords a good example of severe
cerebral hjperaemia passing into actual meningitis.

No. 7. — J. C, set. 51, admitted July 18th. — He was furiously delirious,,
so that it was necessary to confine him. His pulse was strong and vibrating,
but uncountable at first from the continual movements of the arms and body.
Two hours later it was 124. The forearms were tensely flexed at an acute
angle on the arms, and could not be extended without causing pain to the
patient by the attempt. The jaws were firmly closed, the muscles of the lips
in continual motion, as were also the lower limbs. Sensibility of surface
not impaired. Epigastrium tender. Tongue dry and red. He continued
in much the same condition till his death, July 20th. P. M. The arachnoid
was thickened, and of brown red colour; the vessels were so injected that
their minutest ramifications could be traced. At the posterior part was a
false membrane saturated with the red colouring matter of the blood. The
arachnoid of the cerebellum was in the same state. The gray substance of
the brain was of a remarkably deep red. The vessels of the corpus striatum
were injected. Spleen enlarged and much softened. Traces of former in-
flammation of the stomach, and recent of the intestines.

The distress occasioned by cerebral hyperasmia varies much ac-
cording to the condition of the nervous centre. When this is highly
sensitive and excitable the suffering may be great. Dr. Williams
(C. J. B.) narrates the case of a gentleman subject to attacks of de-
termination of blood to the head, which caused him so much suffer-
ing and loss of moral control, that he cut his throat to destroy his
life. Whilst recovering from the wound attacks came on first with
heating of the carotids, then with flushing of the face and head,
suffusion of the eyes and feelings of distraction in the head. A
writer in the Journal of Psycholog. Med. (Jan. 1863, p. 50) says :
" Even in healthy persons, or persons of plethoric habit, this deter-
mination of blood may occasion transient delirium, with various signs
of encephalic disturbance, such as extreme sensibility to light and
sound, restlessness, pain in the head, and visual hallucinations. A
flood of distorted ideas flows through the mind, and overwhelms it ;
bewilderment and incoherence follow, and for the time being the
patient is to all intents and purposes maniacal."

Causes. — Hyperaemia of the encephalon will be induced by all
stimulating agents which act directly on its tissue, and excite it to
increased functional activity. The chief of these are alcoholic
liquors ; small doses of opiUm and camphor have a similar effect.
The hyperaemia thus produced is secondary. Various conditions
5

66 HYPEREMIA OF THE BRAIN.

causing paresis of the vasomotor nerves of the cerebral arteries
•will also give rise to hypersemia, which in this case is primary and
pathological. It is no uncommon thing to meet with persons who
flush very much in the face after a meal. A lady under my care
suffered so much in this way, her face and neck becoming of a deep
red, that she was unable to dine out. She was of a highly sensitive
temperament, and had occasionally some choreic symptoms. Mr.
Langston Parker, in his excellent work on the stomach in its morbid
states, relates (p. 258) the case of a lady, who when placed under his
care had recently recovered from hemiplegia of the right side, but con-
tinued to have pain and throbbing in the head, thirst, flushing of the
face, and occasional numbness of the limbs. The head was continu-
ally hot, the seat of severe pain at the vertex with occasional violent
and sudden darting pains through it, which made the patient scream
out ; the carotids and temporal arteries throbbed violently, and the
pulsations were seldom less than 100 per minute. The epigastrium
was the seat of a violent beating, was full and hot, exceedingly tender
on pressure, and the seat of internal pains shooting into the hypo-
chondria, where she had alsp fixed uneasiness. The stomach and
intestines were become so morbidly sensible to impressions, that
everything she took produced pain, sickness, and very frequently
vomiting; there was constantly an intensely acid taste in the mouth.
The patient had previously been recommended rich diet and stimu-
lants. She was now treated with a few leeches to the epigastrium,
and a nightly mercurial aperient ; which brought away at first pitchy
stools. Her diet consisted of farinaceous food. In a week she was
well. Several other interesting cases of a like kind are recorded.
Mr. L. Parker seems to consider that the irritation of the stomach
Was directly conveyed to the brain, and set up there a similar con-
dition. When, however, we consider that the only direct connection
of the stomach with the brain is by means of the pneumogastric
nerves, which are implanted in the medulla oblongata as their centre,
and that there was no special disorder of the respiratory function,
we shall, I think, be inclined to admit that the gastric irritation
affected the brain in a different way. This probably consisted in a
morbid impression being conveyed by the sympathetic nerves of the
stomach to their ganglia, and thence to the vaso-motor nerves of
the cerebral arteries which in consequence became dilated, and thus
hypersemia ensued.^ The vaso-motor paresis, in such cases, is of
the inhibitory kind explained at p. 22. The extensive diffusive
character of the cerebral irritation, in these cases, and the non-pro-
duction of organic disease, at least for a long time, indicate pretty
clearly that the morbid action is not actually located in the cerebral
tissue itself. In not a few cases determination of blood to the head
is dependent on a primary state of paresis in the nerves of the cere-
bral arteries.

' The record shows that the carotid and temporal arteries were paralyzed.

HYPEREMIA OF THE BRAIN. 67

It is a very curious and important fact, which is mentioned by
Kussmaul and Tenner, and which would not, I think, have been an-
ticipated a priori, that releasing the carotid arteries from compres-
sion causes intra-cranial hypersemia. It almost seems as if the nerv-
ous tissue by the temporary deprivation of blood was brought into
a state of excitability, which induced it subsequently to attract the
blood with more force. Or where the arteries have been occluded
by a spasm of their own circular fibres it may be presumed that this
as it yields is succeeded by a state of paresis and dilatation. The
following case exemplifies this : —

No. 8. — A merchant, set. 65, seen in consultation with Dr. Barrett, Oct.
10th, 1861. He had in July a first epileptoid seizure preceded for some
hours by hemiplegia, which passed off with the fit. A second attack
occurred on the morning of the 10th ; he lay in coma till the morning of the
11th, and was gradually recovering the following evening, but not yet wholly
conscious. The circulation after the fit at first was depressed, but by the
evening it became very active in the scalp and ears, which were red and hot,
and did not give a pale spot on pressure, not even for an instant, after the
compression ceased. On account of the manifest determination to the head,
and the danger of effusion, ^iv of blood were taken by C. C; the night of
the 10th, he had also calomel, and enema terebinth. The urine after the
attack was free, highly albuminous, not high-coloured, sp. gr. 1022, deposited
lithates on standing. 14th. The stupor has now nearly passed off, though
his mental faculties seem rather torpid. Has passed two very dark scybalous
motions. Tongue clean. Heart rather enlarged, otherwise apparently nor-
mal. Lungs healthy. His legs have been enfeebled for some months past ;
he walks like a person crippled by rheumatism. Has been generally very
healthy. May 9th, 1862. He has remained pretty well till two or three
days ago, when he had an attack of stupor without convulsions. He was
relieved immediately by mild purging, and is now tolerably conscious.
Pulse of apparently good force, large, Grets weaker in walking. Urine
continues constantly albuminous. Some months after he had another attack,
and died comatose. Remarks. — This case is one of great interest in more
respects than one. It illustrates very well the occurrence of coma together
with an over-active state of circulation as a sequel of epilepsy, and the dan-
ger that this hyperasmia may occasion if excessive. It also indicates the
probability that hemiplegia may in some instances depend on a similar patho-
logical condition to that which gives rise to convulsions. It seems for
instance tolerably certain in this case that the hemiplegia, which disappeared
so speedily, depended like the convulsions on closure of the cerebral arteries;
only that during the palsy a different set of vessels was affected, perhaps
those of one hemisphere and one corpus striatum only. Subsequently the
arterial spasm became more general, and involved the vessels of both sides,
and those of the excitable districts. In the attack of stupor without convul-
sions the arteries of both hemispheres were probably constricted. The renal
affection, I believe, only so far contributed to the nervous disorder that it
rendered the blood less fit for maintaining healthy nutrition, and so induced
a state of weakness and excitability of the nervous centres. The loss of an
autopsy is much to be regretted, still it seems tolerably certain from the
absence of permanent morbid phenomena that there was no material organic
change, except perhaps in the lower part of the spinal cord giving rise to the
paresis of the lower limbs.

68 HYPEREMIA OF THE BRAIN.

Malaria is of course the great cause of cerebral hypersemia in
inter- and re-mittent fevers. This complication is not so frequent
among us as it is in tropical climates ; it is nevertheless occasionally
met with, and according to my experience most often among children
in that form of disorder which I have termed malarioid remittent.
Exposure of the head to the rays of a powerful sun seems certainly
to cause in some cases cerebral hypersemia. Dr. Murray, quoted
by Sir R. Martin, thinks that this effect is to be distinguished from
that of the same temperature in the shade where the action of the
heat is more general. In this view I quite concur. The phenomena
in the latter condition seem to be essentially those of extreme ner-
vous exhaustion, which we shall subsequently examine. Dr. West
mentions an instance in which exposure to the sun's rays clearly
induced an inflammatory state of brain. Burns, as in a case I
shall presently relate, sometimes have a similar effect. The injury
to the skin causes inhibitory paralysis of the cerebral vessels, from
which hypersemia results. The poison of the exanthemata before
the eruption appears, i. e., before it directs its action to the vaso-
motor nerves of the skin, often causes considerable cerebral conges-
tion, apparently from direct irritation of the brain. Dental irrita-
tion in children is a frequent cause of cerebral hypersemia, the head
being hot, the anterior fontanelle prominent and pulsating strongly,
the brows knit, and the skin febrile. All these symptoms subside
on the tooth passing through the gum, or sometimes on effectual
lancing. I have seen the flushing of face subside in a few minutes
after the gums were lanced in a child who had just had an attack of
convulsions succeeded by stupor. In this case it seems to me certain
that the convulsions and the cerebral hypersemia were caused by
the uprising tooth (a posterior molar); the question is how. The
convulsions probably depended on the increased excitability of
certain parts of the brain affected by the irritation. The hypereemia
from its involving the extra- as well as the intracranial parts, and
from its speedy subsidence on removal of the exciting cause must
have been owing to inhibitory vaso-motor nerve paresis.

The morbid changes produced by cerebral hyperasmia are well
exemplified in the following case.

No. 9. — J. R., m., set. 16, ad. Nov. 11th with a burn of the third degree
affecting the lower part of his abdomen, and the upper and inner part of his
thigh, as well as the genital organs. The shock was severe. Pulse feeble.
Respiration slow. Pain severe at night. On the 13th an erythematous
eruption appeared on the chest and abdomen closely resembling that of scar-
latina ; the tongue also was in a very similar state to that observed in this
fever. He passed two very delirious nights; on the 15th the eruption
became more dusky, the hands and feet cold, and he sank at 2 P.M., having
been perfectly sensible before death. At the autopsy there was found extra-
vasation of blood under the scalp, and effusion of blood between the dura
mater and the bone. All the membranes of the brain congested. Effusion
of fluid beneath the arachnoid. The white substance displayed numerous

HYPEREMIA OF THE BRAIN. 69

puncta vasculosa. The ventricles did not contain an abnormal quantity of
fluid. The lungs and all the viscera were congested. Brown-Sequard's
experiments have shown that the various remote effects produced by burns
are brought about through the intermedium of the spinal cord, which he
regards as reflecting the irritation from the burnt part of the secondarily
affected organs. In my opinion the remote action of the burn is not on the
tissue of the organs themselves, but on the vaso-motor nerves of their blood-
vessels, which in consequence of the morbid impression are paralyzed. It
seems in this case, as not uncommonly happens in such instances, that the
textural quality of the minute vessels was impaired so that extravasation of
the blood ensued. Paralyses of vessels are, I think, not unfrequently asso-
ciated with such loss of retentive power in the capillaries. Common epis-
taxis with its cure by putting a cold key down the back affords an example
where a like state is remedied by the tonic effect of cold acting on vaso-motor
through afferent nerves of the cord. The resemblance of the eruption to
that of scarlatina in this instance was very close, the chief difference being
that the face was but little affected. The mode of causation in both I believe
to be the same. It seems distinctive of reflex vaso-motor paralysis that the
hyperaemia it produces is diffuse, while that of tissue irritation is more local-
ized and tends more to exudation and suppuration.

The treatment of cerebral hyperaBmia must depend very much on
the view taken of its causation. If it depend on direct irritation as
on heat, exanthematous poison, alcohol, &c., it will be desirable if
the strength of the patient permit, to deplete locally, apply cold,
and promote afflux to the feet by hot mustard pediluvia. Internally
■we may purge, or employ Graves' tartar emetic and opium treatment,
or repeated doses of colchicum. If the hypergemia depend on para-
lysis of the vaso-motor cerebral nerves from malaria, or other influ-
ences, depletory and counter-irritant measures must be adopted to
stave off the risk of hemorrhage or eff'usion if it appear imminent,
and in the remissions nerve tonics, especially quinine, must be admin-
istered to remove the primary paralysis. If the vaso-motor paresis
depend on a remote morbid impression, this must be mitigated or
removed if possible. For this in cases of burns opium is probably
the best internal remedy, and a continuous warm bath the best ex-
ternal. Hebra^ relates that he kept a patient who was severely
burnt continuously immersed for 21 days with the best effects.
Another patient with a frightful and inveterate pemphigus was
kept in the bath 100 days with the best results. The soothing
influence of moist warmth takes off the depressing inhibitory influ-
ence. Mr. Windsor's experience is to the same effect (v. Syd.
Soo. Year. Book, 1863, p. 205).

The following cases of hypersemia are of interest:—

No. 10. — E. L., f., get. 16, ad. Aug. 20th. Ill three weeks; complains
of a burning flushed state of both sides of face, extending to the head, which
puts the head into much pain, makes it feel hot. She is obliged by attacks

• "London Med. Rev.," Jan. 1860.

70 HYPEREMIA OF THE BRAIN.

of this kind to go to bed every day. They occur indifferently at all tinaes
of the day. She sleeps well at night. Digestion weak. Tongue clean.
Bowels open. Pulse soft. kShe continued under treatment till November
21st, when she was well enough to be discharged. After she had improved
I noticed one day that one cheek only was hot, the other being cold. The
remedies employed were strychnia and tr. ferri muriatis, and assafoetida.
Tannin with gentian and henbane benefited the digestion, but the disorder
was certainly not chiefly if at all of gastric origin. It was a primary pare-
sis of the nerves of both external and internal carotids, as evidenced by the
juvantia and the general character of the symptoms. It is very evident
how a depleting lowering treatment would aggravate such disorder.

No. 11. — Gh., m., aet. 55, of short, broad make, very short neck. Has
been suffering two or three years with an uncomfortable sensation in his
head, most felt on the right side, but extending all over it, not worse on
lying down, but much increased by a warm close atmosphere, and relieved by
the open air, and by cold bracing weather. Seems to be of excitable tem-
perament. If he goes to church can only stay for about an hour, after
which he gets so excited and irritable about the head, that he is obliged to
come out. His bald scalp flushes with blood while I speak to him. Head
apt to be hot, when he is better is cold. Has rushing noises in the head.
Feels sometimes weak in his legs, and is relieved by a purge of blue pill +
scammony -f jalap. Is not subject to rheumatism or gout, nor is the latter
in his family. Urine free and natural. Heart's sounds and position normal.
No indigestion. Pulse 75, of moderate force. He was ordered nitric and
hydrocyanic acids with cascarilla infusion ter^ and quinine, tannin, and
henbane in a pill his die. This treatment proved decidedly beneficial ; he
found more inclination for mental work, and less tendency to procrastinate.

In the latter case it was remarkable Jhat the patient did not find
the uneasiness in the head increased by lying down. The same was
observed in another patient, whose symptoms were very similar, the
carotids throbbing strongly, but who stated that his head was re-
lieved by the recumbent posture. In one of the epileptic series the
same is mentioned. It is not easy to explain this peculiarity, per-
haps it may depend on the heart's action becoming less in the re-
clining position. Even when the cerebral hypersemia is of traumatic
origin the same is sometimes the case.

No. 12. — J. H., m., get. 16, ad. Sept. 13th. Ill seven days, was struck
by a ball on the head the day before he became ill. He has great pain in the
head, throbbing in the temples, nausea and loss of appetite. Head hot.
Has not more pain on lying down. With eight leeches to the temples, a
blister to the neck, some Gray and Dover's powder he soon got well.

It is clear that there was direct irritation of the brain in this
youth, yet he did not need to keep his head elevated. On the other
hand, in the following instance the peculiar attacks seem to have been
promoted by the recumbent posture. H. H., get. 26, a sufferer from
sub-acute rheumatism, but rather inclined to plethora, has seizures
which he describes as follows : They begin with a sense of fluttering

SPINAL HYPERiBMIA. 71

at the heart, and a feeling of fright, then all the blood in his body
rushes to his head, which throbs violently, and seems full as if
bursting. This state lasts five to ten minutes, during which he can-
not move at all, tries to move but can't, is however quite conscious.
The attack subsides spontaneously. It always occurs at night while
he is lying down. It is worth observing that neither in this nor in
five or six other cases of cerebral hypersemia were there any convul-
sions. In Nos. (10) and (11) the pathological condition was essentially
different from what it was in (12). There was active hypersemia no
doubt in all three, but in the two first it depended solely or chiefly
on relaxation of the arteries, or vaso-motor nerve paresis ; in the
last it was the result of irritation of the cerebral tissue, and was
produced by a vis a f route. It is evidently a most practical matter
to distinguish cases having one origin from those which have a dif-
ferent. The treatment must be determined by the diagnosis, and
in some cases it is by no means easy. In the case of H. H. I think
there ensued at first a spasm of the cerebral arteries, which was
followed by sudden relaxation. The afi"ection was akin to epilepsy.

CHAPTER VI,

SPINAL HYPEREMIA.

The spinal cord is evidently very differently circumstanced com-
pared to the chief mass of the encephalon with regard to its supply
of blood. That furnished to the latter is very abundant, and this
large amount appears to be necessary for the due performance of
its special functions — a failure or diminution of the supply being
immediately felt, while on the other hand an overflow has equally
injurious effects. In the case of the spinal cord these variations
seem to be of much less moment, and we can by no means point
with so much confidence to morbid results produced by them. No
doubt the phenomena of meningitis, and myelitis, or apoplexy are
evident enough ; but these affections do not come within my plan as
they involve actual organic change. With regard to spinal hyper-
emia much importance has been attributed to it by various Conti-
nental writers of an older date as the cause of numerous morbid
phenomena. Frank imputes certain pains of the back and lower
extremities, certain sciatic neuralgias, certain species of lameness,
divers tremors and convulsive movements, stupor or paralysis of
those extremities as well as several epileptic and tetanic phenomena
to congestion and distension of the vertebral sinuses and veins (Olli-
vier). Ludwig also views the very acute dorsal pains which so often
exist in severe intestinal colics, and the pains in the back and limbs

72 SPINAL HYPER-aiMIA.

which occur at the onset of fevers as depending on a like condition.
Portal explains convulsive and paralytic affections of the extremi-
ties occurring in various inflammatory diseases by congestion of
the spinal vessels. Ollivier relates the following case. " I exam-
ined the body of an individual who had been affected with incom-
plete paralysis in the movements of the trunk and extremities with
morbid exaltation of the cutaneous sensibility. This paralysis . . .
had gradually diminished and was nearly gone, when it again ap-
peared simultaneously with a pleuropneumonia. This latter disease
made rather rapid progress, and the paralysis was observed to go
on increasing till his death ; so that a few days before he died the
patient had relapsed into the same state of paralysis with extreme
sensibility of the integuments. The upper and lower extremities
performed but very feeble and general movements ; respiration was
extremely painful, and the movements of the chest were almost im-
perceptible. He preserved to the last the free use of his intellects.
At the post-mortem we found rather extensive pneumonia and pleu-
ritis of the right side ; there existed at the same time considerable
sanguineous congestion in all the meningo-spinal veins, which were
manifestly dilated. The nervous cords were enveloped in a collec-
tion of veins very much gorged with blood, which evidently com-
pressed each spinal nerve at its exit from the spine, a circumstance
which perfectly explained the phenomena observed during* life."
Another case is related (from Dance), the subject of which was a
female, set. 31, who a month after a favourable confinement was
attacked with formication of all the limbs, which speedily became
paralyzed, while sensibility remained. The respiration became
difficult and she died asphyxiated on the second day, having been
bled twice. A very careful examination showed nothing abnormal
in the brain or cord. All that could be detected was some red
points on the cut surface of the brain, and slight infiltration of the
cellular tissue of the spine external to the dura mater. The organs
were all sound. 0. explains the paralysis by the assumption of a
congestion, which disappeared after death. This assumption seems
to me quite inadmissible, for the death was of that kind which spe-
cially ten.ds to increase and perpetuate venous congestion by reason
of the impediment to the return of the blood to the right heart.
There was just as much reason for finding the venous plexuses
gorged in this case as in the preceding, and I must think the ex-
planation of the paralysis in both is erroneous. The loss of motion
alone cannot be explained so far as I can see by the congestion, as
the distended veins would press equally on both anterior and pos-
terior nerve roots. Nor can I admit that the cord surrounded as
it is by subarachnoid liquid is at all more likely to be compressed
at its anterior than at its posterior part, because the former is nearer
to the wall of the canal. These cases afford a good illustration how
much more prone we are to be impressed by the visible than by the
invisible, though the former may be very inadequate to account for

SPINAL HYPEREMIA. 73

the phenomena. A case which ended in recovery is given hy the
same author. The patient, set. 38, led an active and laborious life,
but was habituated to alcoholic and venereal excesses. The latter
especially induced a pain in the loins and trembling of the lower
extremities. For two months before his attack he had general de-
bility of the legs and wandering pains, yet followed the same mode
of life. It was not surprising that paralysis of all the limbs, and of
the erector spinse muscles should have ensued with some numbness
and sense of formication. Venesection was useless, and after the
application of twenty leeches to the back the paralysis became com-
plete. After four blisters there was some improvement, but nux
vomica given in gradually increasing doses was of no avail, and was
discontinued, only dry frictions to the spine and to the extremities
were occasionally employed. After three months' illness the paraly-
sis entirely disappeared. The cause assigned for the paralysis by
Ollivier is the recurrence of sanguineous congestion, and increased
exhalation of the vertebral liquid. I cannot but think that a more
natural and truer reading of the case is that the essential pathologi-
cal condition was exhaustion of the nerve-power of the cord, which,
with rest, was gradually restored. On reviewing the above cases,
which seem to be fair specimens of the kind in question, I cannot
but join with Abercrombie in feeling considerable doubt how far
spinaPhypersemia (venous) is ever a- cause of failure of the functional
power of the cord. Arterial (true) hypergemia we may be sure would
(supposing it to exist apart from actual inflammation) lead to in-
creased activity of the nervous tissue, such as exists in tetanus and
in similar states. It is impossible, however, to separate the effect
of the hyperaemia in such instances from that of the agent, as
strychnia, which has induced it. Duclaux^ has recently described
as spinal congestion various phenomena, which were produced by
excessive heat, and which were evidently very similar to those of
heat-apoplexy. Patients were suddenly attacked with headache,
muscse volitantes, general cyanosis, and derangement of the digestive
functions. Insensibly and in a short space of time there occurred
a failure of strength in the limbs, substances held in the hands were
permitted to fall listlessly to the ground, and the gait became
uneven and irregular ; there was giddiness and frequently syncope.
Pain was commonly complained of at different parts of the vertebral
column. Antiphlogistic and purgative treatment was usually suc-
cessful, especially mercurial friction along the spine. Blood-letting
was seldom required. The symptoms in these cases appear to me
to have depended much more on a state of paresis, of exhaustion
and enfeeblement of the nervous tissue than an active hyperaemia.
The morbid influence of heat is invariably depressing. It is very
possible that active hyperaemia did occur secondarily to some amount,
and the results of treatment go to prove it, but I cannot view this
as the primary morbid change.

J Lond. Med. Gaz., Aug. 1860.

74 CEREBRAL PARESIS.

I conclude this subject with expressing my entire concurrence in
Kussmaul and Tenner's 22d conclusion, and in extending it to the
spinal as well as the cranial cavity. The last few hours of life must
almost invariably induce considerable alterations in the distribution
of blood, and we know that even after death the position of the
corpse has a very considerable influence.

CHAPTER VII.

CEREBRAL PARESIS.

By this term I mean a state in which without demonstrable
organic change there is greater or less enfeeblement of the func-
tional power of the brain. Perhaps the simplest instance of it is
when after much exertion of mind or body we feel incapable of any
sustained mental effort. By repose the functional power in case of
mere fatigue is early restored, but in various morbid states repose
alone is insufficient. Prolonged extreme mental exertion may in-
duce such a degree of paresis as to constitute dementia, and the
same may result from any severe mental shock. The non-dependence
of this state on actual organic alteration in some cases is evidenced
by the temporary restoration of the intellectual power under stimu-
lants, as wine. Paresis may affect any or all of the cerebral func-
tions, either the intellectual, or the voluntary motor, or the sensory.
The liability to paresis will vary much according to the original
vigour and endowments of the individual, and also according to the
wear and tear to which he has been subjected. The phenomena of
cerebral paresis are of course very varying, but all bear the stamp
of debility, mingled it may be in certain cases with indications of
abnormal excitability. In many instances the phenomena of primary
cerebral paresis and of general anaemia will be very similar, the
anaemia in fact being the cause of the failure of power. Paresis,
however, is most often quite independent of anaemia. In some cases
paresis of the brain seems to be the reflex of inhibitory irritation.

Instead of attempting to give an abstract description of the state
in question, I propose to record briefly the leading features of various
cases I have met with, which as actual occurrences seem to me more
impressive than any general statement. A lady, aged 80, of strong
constitution, calm mind, and energetic disposition, had a moderate
attack of influenzal catarrh. In this she had the following symp-
toms referable to the head. She lay in a dozy torpid state, the
stupor being so marked that she could hardly believe she had
not taken opium. If she did not get her food when she wanted it
she felt as if her understanding were leaving her. Bark and am-
monia with wine benefited her, but even some days later, when con-

CEREBRAL PARESIS. 75

valescent, she could only lie quite still without speaking or doing
anything, and felt as if she had no use of her mental faculties.
The pulse was intermittent, but not specially weak. This was an
instance of simple paresis of the hemispheres. F., male, of middle
age, stout, is attacked suddenly one evening with faintness, giddiness,
severe retching and vomiting. He could not stand, and his head
felt as if it did not belong to him. He had felt unwell during the
day, but the faintness, giddiness, and sickness came on all in five
minutes. There was no epigastric tenderness, no headache, no pain,
but drowsiness. He could not raise his head, except for a short
time when he was sick. In four or five days the sickness had sub-
sided, and he was gaining strength, but was only just able to read,
and his head was still very apt to be giddy on any quick motion. His
tongue was clean all the time, and his pulse not at all weak corres-
pondingly to the peculiar debility of the head. Under a tonic
treatment he recovered, but it was long before he lost the tendency
to giddiness. In this case it is clear, I think, that the brain was
affected by a stroke of influenza, which partially paralyzed its action,
and perhaps also that of the vagi nerves. There was no indication
of cerebral anaemia, the giddiness seemed to be the result of direct
debility, which continued for a long time. — R. F., set. 17, male,
admitted January 28th. He complained of stupidness, nervousness
all over, a great sense of weight at the vertex, and great sleepiness.
Functions in fair order. With ammonia, iron, nux vomica, and
valerian he was well in three weeks. The cause of the disorder is
not clear in this instance, but it is evident that the cerebral func-
tional energy was impaired.

M. W., set. 8 1, female. She has been ailing with nerve disorder ten
to eleven months, has improved much on tonic treatment, but has re-
lapsed last fourteen days. She has been at school, and has been
over-exerting herself a little. She is silly, irritable, and bad tem-
pered in mornings, and then her right arm gets affected with shaking,
and her right leg aches, and the foot is everted, so that she cannot
walk. At the same time her speech fails, and she stutters. At
times she gets quite unconscious; the other day she was so for some
hours ; she then is pale, and makes a snoring noise in breathing
(paralysis of the velum palati). The unconsciousness is apt to come
on when she is tired. Has pain in back at times, but there is no
tenderness in the spine on percussion. No ansemia. In this case
the general condition was allied to chorea, but there was disorder of
the intellectual centres as well as of the motor. — M. H.,set. 11, female.
Ill two months, right side is partially paralyzed ; her movements
are also unsteady as in chorea; cannot grasp anything with the right
hand. Leg dragged ; tongue drawn to one side ; functions in good
order. With strychnia, iron, and chloric ether, she got well in less
than two months. There can be little doubt, in this case, that the
brain was the seat of the disorder from the unilateral character of
the affection. The motor centre was weak and irritable, and as it

76 CEREBRAL PARESIS.

regained tone and power under the use of the rohorants, recovery
ensued. This clearly was a paresis. — J. J., male, set. 17, ill with
catarrh fourteen days. Stomach disordered, memory much impaired,
cannot be trusted alone ; appears very nervous ; speech impaired and
power of holding things in his hands; is ready to fall if at all irritated
or startled. Of large lax make. In three weeks he was cured by iron,
quinine, and nux vomica, after three mild aperients. — F. F., male, set.
14, ill fourteen days. Seems silly, strange, and very wandering, but
answers questions. Pulse slow, weak. No other apparent disorder.
Recovered in three weeks with quinine and nux vomica. — L. W.,
set. 13, female. Health generally good, ill three weeks. Was at-
tacked at first, at 10 A. M., by a kind of fit; lost the use of her
legs and arms ; her speech was quite altered ; she looked livid ; and,
according to her father's account, appeared " taken for death." She
did not recover consciousness by the evening of the day on which
she was attacked. At the time of her admittance she had in great
measure regained the use of her limbs, but still could not dress or
undress herself; she often complained of pains in her arms, more
in her head. She recovered with iron, quinine, cod-liver oil, and
nux vomica in eight weeks. In the last three cases the symptoms
indicate that the brain had been affected by some depressing influence
interfering more or less seriously with the exercise of its functions.
Of the nature of this influence there is no certainty, but it seems a
probable conjecture that it is some miasm akin to that which pro-
duces epidemic catarrh. The length of time during which the mor-
bid phenomena continued makes it certain that they were not of
epileptic or syncopal character. Neither is there any indication of
their resulting from reflex inhibitory irritation. I have chosen to
. record the above instances, not because I think them very unusual,
but because their import scarcely seems to be appreciated by prac-
titioners generally. It is to my mind a capital fact in neuro-pa-
thology, that the great nervous centres are liable to have their
functional power so seriously impaired by obscure (atmospheric)
causes, apart from any organic lesion, or manifest cause of debility.
It is clear that the nervous centres may be vexed and depressed by
the same kind of agencies that harass the nerves. They may also
become gradually debilitated from various causes till they give way
in a sudden collapse. This should be born in mind in dealing with
all obscure cases of central aff"ection.

Dr. Prichard applies the term leipothymia to certain fits of epi-
leptic character, "consisting in a sudden loss of sense and con-
sciousness, the muscular system being relaxed, and the patient
lying in a state resembling sleep, at the same time without that
state of the circulation which is peculiar to syncope." The afi"ection
does not appear to be a frequent one. In the only case where I
remember to have witnessed it there was no indication of cerebral
ansemia, but extreme weakness of the nervous system generally.

The following quotation from Mr. Austin's work on General

CEREBRAL PARESIS. 77

Paralysis affords a well-marked example of the production of
cerebral paresis, of the most complete kind, by remote irritation.
The paresis in these cases is of inhibitory character, and is the
result of two factors, viz., on the one hand the impaired state of the
vis nervosa in the encephalic centre, and on the other the intestinal
irritation. That the paralysis is not the result of spasm of the
cerebral bloodvessels is apparent from the gradual manner in which
recovery takes place in most instances, unlike the complete cessa-
tion of the phenomena as soon as a fit of epilepsy has terminated.

" A recognized paralytic is suddenly found completely hemiplegic.
The fit, which usually happens in the night, is unattended by shriek
or scream, and is frequently free from convulsion. It is accompa-
nied by semi-coma and suspended utterance, and often announces
itself to the attendants or to the sufferer's fellow-patients by loud
teeth-grinding, or by the seized person falling out of bed. Then
the neighbours find he has fallen because an arm and a leg are
powerless. Frequently the paralytic who may have been retained
in bed by the well-tucked-in clothes is only discovered to be hemi-
plegic when the attendant comes to get him up in the morning.
When he comes under medical inspection he is semi-comatose, his
utterance is in abeyance, he is quite hemiplegic, but with sensatipn
only slightly impaired. If the arm or leg be pinched, vigourous
movements of the affected limbs ensue. Though sometimes appa-
rently insensible to all going on around him there is frequently a
hopeful glimmer of intelligence in the eye. The mouth is rarely
distorted, and the movements of the eyeball are more perfect than
might have been expected. The pupils are more unsymmetrical
than usual. An attendant now administers an injection of eight
tablespoonfuls of common salt dissolved in a pint of warm water.
In nine cases out of ten, in at most an hour, a copious stool is the
result, composed of small, hard, quite distinct rounded lumps.
After an evacuation of this kind I have known a person quite hemi-
plegic at 2 P. M. recover a free mobility of the arm and leg by mid-
night. Usually, however, several similar enemata and their result-
ing stools are required before an approach to the ordinary move-
ments of the limbs is obtained. Occasionally castor oil, and calomel
-f colocynth are employed the sooner to clear out the intestinal
tube, or at least the large intestines. The object of these simple
remedies is not, by serous evacuations to derive from the head, but,
simply to expel the hardened feces, of which the colon is full, and
which I regard as the eccentric cause of the seizure. The cause
removed, nature aided by a moderately generous diet, will soon
restore the affected limbs to their former condition. Such measures
as blistering, cupping, leeching, purging, and the like, are not only
superfluous, but I believe in the highest degree prejudicial during
these seizures. At any rate without their exhibition I have seen
nearly weekly rapid recoveries from the completest hemiplegia.
Under injections, castor oil, a pill of col. c. calom. in a day or two

78 CEREBRAL PARESIS.

the patient's leg begins to move, and his utterance for monosyllables
to return. Later the movements of the arm commence, and the
memory becomes sufficient to enable him to recognize and name
correctly those around him. Day by day the amelioration proceeds ;
and I have frequently seen a person, hemiplegic for the first time a
week previously, again walking, and with his former gait in the
infirmary. Usually, however, two to three weeks may elapse before
the patient quite regains his former mobility. During this time all
that is required is simply to watch, and gently to sustain the peris-
taltic action of the intestines."

Dr. Palmer records' the following interesting case, which seems
to me plainly of reflex inhibitory nature : —

No. 13. — A. B., set. 63, a temperate male, free from rheumatism, gout,
or constitutional syphilis; has no teeth, but eats meat. April 4th, 1859, he
was suddenly seized in the morning with left side hemiplegia, which was
almost complete. His face was pale, he looked dull and bewildered. He
was laid horizontal, cold applied to his bald head, and calomel gr. iv given.
Marked improvement ensued in two hours, and the bowels acted two or three
times. He felt much better, and had regained considerable power over his
leg and arm. Six leeches were applied to the temples, salines, and ape-
rients given. In four days all paralysis was gone. He remained well for
four years except an annual attack of bronchitis. He still ate meat with
toothless gums. Early in 1863 he began to have irritation of the diaphragm,
and unbearable restlessness and oppression in the early morning. Subse-
quently his mind became enfeebled, any trifling business matter threw him
into a state of agitation, excitement, and sense of impending death or insan-
ity. Then he became the subject of severe nervous dyspepsia. Marked
and complete relief was afi"orded by narcotics, but after a few days the effect
was lost, and he was worse than before. All this time his tongue was
almost perfectly natural, the bowels acted regularly every day, the head was
hot, and the temporal arteries pulsated rather strongly. The cerebral irri-
tation was justly regarded by Dr. Palmer as the analogue of the past hemi-
plegia. It was however unrelieved by a great variety of treatment including
repeated aperients, stimulants, and complete rest of mind and body, until, on
Dr. Goolden's advice, a larger dose of calomel was given followed by a pow-
erful cholagogue of manganese. This brought away a large quantity of very
offensive feces, and the patient was permanently and completely relieved.
His mental faculties were quite restored.

There can be no question that on the second occasion the morbid
impressions conveyed from the intestines affected the brain directly,
enfeebled and disordered its actings. The state of the circulation
in the scalp makes it almost certain that the brain was not ansemic,
rather the reverse. In the first attack it is uncertain whether the
hemiplegia should be referred to arterial spasm, or to inhibitory ir-
ritation. The pallor of the face and the suddenness of the seizure
point rather to the former as the more correct view. If this be so,

« Lancet, Dec. 19th, 1863.

CEREBRAL PARESIS. 79

we must regard the vaso-motor nerves as primarily affected in the
first case, the hemispheres in the second.

In the following case the cerebral disorder appears to be plainly
referable to gastric distress, which acted in the same way as the
intestinal irritation in the preceding : —

No. 14. — Mr. "W., m., set. 42, seen Sept. 26th. Ill since the previous
November, has been unable to sleep at night for a long time until latelj, has
lost flesh and got rather weak. Has very marked tenderness in the region
of the stomach, particularly at the epigastrium, which has increased lately,
and pain after food. The uneasy feeling in the stomach comes on in such a
way at times that he is obliged. to run out, or move about in some way; he
feels as if he should go out of his mind. Has had strong suicidal impulse
while suffering from the pain. Sometimes gets relief from crying. Says
he does not know whether his mind or his body is affected, but strives
against it all he can. Has conceived a dislike of his best friends. Does
not appear at all hypochondriacal. Is a temperate man, can't take wine or
beer, but has been obliged to take several glasses of neat brandy at night to
make him sleep; the brandy does not affect his head as it used, but seems
to go to the stomach and relieve it. Used to have piles, but not bleeding.
Bowels regular. Pulse weak, quick. No tumour in stomach. Liver and
spleen not enlarged. Lips rather anaemic. Heart's sounds normal, except
the second, which is not quite pure. Urine generally clear, deposits a very
few small oxalate of lime crystals. Has much flatulence. He had a mor-
phia-dressed blister to the epigastrium, and took a mixture of tr. cinch. +
tr. valerian, -f- tr. hyoscyam. + ammon. carb. + inf. valerian, ter die, and
ferri carb. saccht. ter die. By Oct. 9th he was decidedly better, sleeping
very well; his epigastrium was almost quite comfortable, he could take a
beefsteak very well.

The causes of paresis of the encephalon are all such as produce
nervous exhaustion. Excessive mental toil, monotony, unhealthy
malarious climates, oppressive heat, venereal excess, and influenzal
miasms, are the principal. The possible dependence of the prostra-
tion on some inhibitory irritation should be borne in mind. The
injurious effects of overwork of the brain are well known. I should
not do more than name it here, were it not that I would fain add
my voice of warning to those which have already been given. Al-
most while I write, a youth is brought to me, whose father is intent
on pushing him forward in his studies, unheedful, though a kindly
parent, of his son's failing nervous power, as marked by an abdominal
neuralgia, pallor, nocturnal restlessness, and a sense of unusual in-
capacity for mental exertion. Stern necessity may oblige those
who are engaged in the thick of the battle of life to strain their
powers beyond what is prudent, but in the case of those who are
being trained for the strife all approach to such over-exertion should
•be discountenanced. It is sad when early promise of excellence is
blighted by inevitable destiny, but much more sad if the collapse
must be attributed to our own want of care. The ill effects of mo-
notony are best illustrated by the languor, ill health, and sometimes

80 CEREBRAL PARESIS.

mortal disease which are apt to ensue among soldiers and sailors
when reduced to compulsory inactivity ; while cheerful excitement
ha& an almost magical opposite effect. The melancholy chant of •
the Count of Toulouse^ expresses no futile apprehension.^ Nature,
in her insatiable love of variety, in the changing seasons, and the
ever-varying weather, seems to indicate clearly enough the advan-
tage of frequent change. All experience of malaria testifies to its
specially depressing influence on the nervous system, not to mention
the cretins, the inhabitants of malarious districts are spoken of as
feeble in body, and spiritless in mind, phlegmatic and melancholy,
stupid, languid, and apathetic. The action of heat in producing
languor and general enfeeblement of nervous power is a capital fact,
and one I have often thought is by no means sufficiently regarded.
It is surely a very significant circumstance that an ordinary man
can carry, without inconvenience, a heavy overcoat on a cold day,
and walk much further and faster thus laden than he could on a
hot day more lightly equipped. This surely implies a much greater
amount of energy in the motor nervous apparatus in the one case
than in the other. A rifleman will tell you that his aim is much
more true and steady in cold bracing than in warm relaxing weather.
Men endued with great nervous power are capable of enduring heat
much better than others. Napoleon, it is said, when in Egypt habit-
ually wore his coat buttoned up. The British soldiers in India, in
general, bear the fatigue of forced marches under the burning sun
of that climate better than the native Hindoos.^ In fact, the
stronger and better toned the nervous system is the more capable
is it of resisting the enfeebling and enervating influence of heat.
This is very well exemplified in the affection termed heat apoplexy,
of which I propose here to take some notice. Intemperance, espe-
cially in the use of spirituous liquors, predisposes powerfully to this
disorder, and so also do close crowding and bad ventilation. On
the other hand, temperance, cheerfulness, and the energetic pursuit
of duty, have been proved, as in the memorable siege of Delhi, to
have a wonderful influence.^ Paley, with admirable wisdom, re-

' "Oh dear, what will become of us?
Oh dear, what shall we do?
We shall die of the vapours if some of us
Can't find out something that's new."

J. of Psychol. Med., July, 1863.

2 V. also an instance of the appearance of scurvy among American troops, who
were fairly well supplied with fresh food, but who had no active employment, and
became homesick and disgusted with the service. Several died of scurvy. Several
who were sick began to recover from the moment they were told they should have their
discharge. — Amer. Med. Times, June 1st, 1861.

3 Alison's "Hist, of Europe," vol. xvi. p. 71, note.

* Sir R. Martin writes, p. 410 of his work : "Officers before Delhi describe them-
selves as marching all day in the sun of June, July, and August, and serving in the
burning trenches for weeks together; and yet they preserved their health under a tem-
perature of 130° or more through temperance to a wonderful extent." Contra, Dr.
Barclay states, as the result of his observation, that men whose nervous systems had
been injured by intemperance were much more disposed than others to attacks.

CEREBRAL PARESIS. 81

commends the manful discharge of duty as the best remedy against
"sinkings and oppressions of the spirits." The action of heat,
whether it be direct solar, or a simply elevated temperature, is evi-
dently the prime motor of heat-apoplexy, as the other causative
conditions are chiefly predisposing, though in this respect their in-
fluence can hardly be over-estimated. The observable phenomena
will vary according to the particular part of the nervous system,
which especially succumbs under the morbid influence. In the
worst cases where death occurs almost instantaneously the medulla
oblongata is probably the focus of morbid action. Death ensues
from arrest of the respiratory changes in consequence of the paresis
of the vagi, and the lungs are found intensely engorged, even to
the production of apoplectic extravasation, while the brain is almost
free from lesion. In other cases of slower progress where the dis-
order commences with feverish debility in the morning, and termi-
nates in stupor in the afternoon, the cerebral hemispheres are more
especially affected, their vessels are found exceedingly congested, and
those of the lungs less. Assuming the paresis to be primary, cere-
bral congestion ensues, according to the well-known law that im-
pairment of function is intimately connected with impediment to
the free transit of blood through the part. Thus the lungs become
congested in apnoea. The circumstance that in the milder seizures
the phenomena take the form of fever, either ardent, or remittent,
or intermittent, points to the strong probability that in these in-
stances the vaso-motor nervous system is specially implicated.

I subjoin here the notes of two cases of this affection as it has
occurred in my experience: —

No. 15. — M. G., f., set. 14, ad. July 18th. Ill six days; was out in a
field, sitting in the sun, carrying children, suddenly became faint, and got
pain in the head and vomiting, and has had vomiting ever since. She is
always wanting to lie down, and complaining of her head. Skin cool. Pulse
soft, open. Bowels very costive. Epigastrium not tender. With tannin
and mineral acids the sickness quite ceased in a week, and she was much
better.

No. 16. — E. L., f., set. 24, ad. Oct. 25th. Ill since tbebeginning of August.
" She went reaping without a bonnet, and the sun affected her brains." It
was about 2-3 P.M. when she was attacked, on a hot day with a bright sun.
She was taken up senseless, and remained insensible for one whole month,
during which her head was blistered. Legs have been much swelled, but
are not so now. Has not suffered with pain in head. After the first attack
she used to get slightly chilly in the afternoon, the chill was soon succeeded
by much fever and cold sweats. Abdomen has been much swelled, is much
distended with flatus now. At present she feels very weak and languid, is
very anasmic. Has much nausea, can take no food. Very thirsty. B.
regular. Urine sometimes red, sometimes pale. Head not hot, is rather
better when lying down, " feels lost" when she gets up. Loses conscious-
ness at times, finds her memory failing, spirits very low. Has dreadful cold
sweats at night. The fever affects somewhat a tertian type. Skin cool.
6

82 CEREBRAL PARESIS.

Pulse not particularly weak. She has just returned from Kent, where she
was taken ill. She was ordered quinine ter die with mercurial alteratives
alt. noct ; under which she improved a little, and discontinued attendance.

Remarks. — In both these cases the phenomena are a sudden cerebral
"coup" followed by failure of functional power, and stomach disturbance.
The second case is much the more severe, the prostration was very prolonged
and considerable, and the tendency of the disorder to assume the character
of malarious fever apparent. It seems plain that whatever amount of
hyperaemia of the brain may have occurred, the history is by no means that
of mere cerebral congestion, but rather reminds one of the results of concus-
sion. If we bear in mind the primary exhausting action of heat, it will not
be difficult to conceive how an excessive application of this agent may pro-
duce such phenomena as above detailed. The occurrence of aguish disorder
as the result of severe nervous prostration is highly significant as to the
especial implication of the nervous system in malarious disease.

The after symptoms, as Sir R. Martin well remarks, "are of
extreme interest, and they, as well as the more chronic and subdued
influence of insolation, throw much light on the pathology of the
disease." The list which he gives appears to me remarkably to con-
firm the opinion I have expressed that heat-apoplexy essentially
consists in a functional paralysis of one or more great nervous cen-
tres. It runs as follows : " (1) Severe mental depression with sense
of weariness along the spine. (2) Impression of the sun being always
shining on the person with tinnitus aurium. (3) Distressing formica-
tion sometimes accompanied by a peculiar and general eruption and
desquamation of the skin. (4) Deafness more or less severe with
impaired vision, and inability to use the eyes in reading and writing.

(5) Various paralytic affections, more or less general, as hemiplegia,
and local palsies, as of the eyelids, cheeks, or upper extremities,
with and without loss of sensation. Heaving and difficult breathing.

(6) Distressing hysterical states of the nervous system, with absence
of self-control in laughing and crying — the paroxysms being followed
by great prostration of nervous power. (7) Interruption to natural
sleep with incapacity for any kind of business. (8) Impression of
alarm on any sudden movement of the body, and upon the occurrence
of sudden noises. (9) Sudden epileptiform seizures, without loss of
consciousness, followed by great nervous prostration." The forego-
ing have been observed in sufferers who have returned to England.
In India, he proceeds, " we are familiar with the acute sequelae to
sunstroke, as ardent fever with acute delirium, remittent and inter-
mittent fevers complicated with dysenteries, hepatic inflammations
and congestions." These statements merit the most careful con-
sideration, not only from the light they throw on the nature of heat-
apoplexy, but from that which they shed on the pathology of a mul-
titude of nervous disorders. Any man of experience in the manifold
disorders of jaded and exhausted nervous systems will recognize at
once how close is the resemblance between the results of tropical
heat, and those produced by the ordinary causes in operation among

CEREBRAL PARESIS. 83

the struggling multitudes of our large towns. It may be observed,
(I.) That the most abiding results of heat-apoplexy are almost all
referable to impaired functional energy of the cerebro-spinal system.
(II.) That this impairment shows itself either in motor paralysis (5),
sensory paralysis (4 and 5), either of common or special sensation,
hyper- and dysagsthesia of the nerves of common and special sense
(2 and 3), in debility and undue excitability of the emotional centres
(6, 8, 9), and in similar states of the cerebral hemispheres and spinal
cord (1, 7). (HI.) The earlier sequelae appear as the well-known
consequences of vasomotor nerve paralysis. The picture which Sir
R. Martin gives of the manifold and varying sequelae of sunstroke is
altogether unlike that presented by actual organic disease. It is
unlike in its causation, its non-progressive character, the inconstancy
of the phenomena, and in the " juvantia."

The occurrence of eruption in connection with, and apparently as
the result of cutaneous dysesthesia is of much interest, and probably
may be explained as the result of vaso-motor nerves becoming impli-
cated in the morbid action. It will be remembered that one of the
results of division of the sympathetic in some animals is cutaneous
eruption. Romberg describes in the same way the development of
prurigo from pruritus, a lichenoid eruption from a mere nerve affec-
tion. The action of summer heat in promoting the occurrence of
lichen urticatus is familiar to many of us. The effects of heat-apo-
plexy illustrate very forcibly the development of morbid excitability
and hyperesthesia simultaneously with impairment of motor power.
It is difficult to say how far malarious poison is concerned in pro-
ducing the phenomena we have been considering, probably it acts
chiefly as a predisposing cause. The parallel, however, between
these two morbid agencies is extremely close, and it is curious and
instructive to observe that their results are sometimes identical.
The cause of this correspondence no doubt lies in the fact that both
act principally on and through the. nervous system, and that in the
way of paralyzing its power. Admitting cholera poison to be a form
of malaria, of which I think there is some notable evidence, we find
in some recorded epidemics as sudden a death-stroke as can be occa-
sioned by heat ; malaria will produce various forms of paralysis and
epileptoid attacks, cutaneous eruption, and mental depression, besides
the well-known fevers. This however may be said that malaria affects
more specially the vaso-motor system, and heat the cerebro-spinal.

As an imponderable influence, obscurely though unquestionably
related to heat and malaria, we may notice electricity in its morbid
action on the nervous centres. Dr. Radcliffe states in his lectures^
that a continuous electrical current of low tension seems to have the
power of producing temporary paralysis of a nerve or nervous cen-
tre which is traversed by it. Eckhard has shown that if the nerve
of a frog's leg prepared for the purpose be included in a galvanic

' "Lancet," Feb. 28th, 1863.

84 CEREBRAL PARESIS.

current it is impossible to produce contractions in the muscle by acting
upon that part of the nerve which lie^ between the poles. In other
words the part of the nerve along which the continuous galvanic
current is passing, is paralyzed by the action of the current.' It is
also a fact that the spinal cord may be paralyzed by the same means.
If for example the spinal cord of a rabbit be included in the circuit
of a voltaic battery the part between the poles may be cut, pricked,
torn or even electrified without giving rise either to pain or convul-
sion. Although the above-mentioned effects are expressly ascribed
to low-tension electricity it seems indubitable that a shock of high-
tension electricity produces very similar, and even more abiding.
Numerous instances are on record in which individuals having been
struck by lightning have suffered temporary paralysis of motion,
and' special or common sensation, from which they recovered either
spontaneously, or with the aid of tonic remedies. In these cases
there can be I think little question that the nervous tissue is directly
paralyzed from some molecular change taking place in its cells or
fibres. I once experienced myself a severe shock from a very large
Leyden jar, and well remember the overpowering general prostration
I experienced, although the shock only passed through my forearm.
It is impossible, I think, to conceive that any arterial spasm can
explain the effects produced in this and similar instances. Certainly
in the case of the frog's nerve dissected out, and remaining attached
to the muscle above mentioned, there can be no question of local
anaemia as the cause of the paresis. The " juvantia" also, as in Dr.
Watson's case,^ where steel and tonic treatment effected a speedy
cure of paraplegia in a girl who had been struck by lightning, deci-
dedly indicate that the paresis from this cause is one of simple func-
tional debility.

Venereal excess is a powerful cause of cerebral paresis, as well as
of spinal, few exceed it. Good Hufeland says, " it is proved beyond
all doubt that nothing renders the mind so incapable of noble and
exalted sensations, destroys so much all its firmness and powers, and
relaxes the whole being as this dissipation." It is not too much to
affirm that a state bordering on dementia has often been produced by
sexual excess, and perhaps still more frequently by solitary vice.
Esquirol says that immoral habits and the use of mercury are very
frequently productive of that deplorable species of paralysis which
becomes complicated with dementia and monomania.^ It is somewhat
remarkable that sexual excitement should have so pernicious an effect,
for the nerves of the genital organs are by no means large, their ori-
gin is remote from the brain, and the loss of excreted matter can

' On one occasion I went to sleep with the negative pole of a 40 links Pulvermacher's
chain in my hand, the positive being applied to my back. In the course of the night
I found my hand was quite numb, but after removing the chain the numbness soou
went off.

2 "Lectures," vol. i. p. 332.

3 V. Ritchie on same subject, "Lancet," Feb., March, 1861.

CEREBRAL PARESIS. 85

hardly be regarded as anj serious drain on the system. The only
way that I can see of accounting for the remarkable collapse which
attends on any abuse of the generative faculty is, that owing to the
intimate commissural connections between the lumbar enlargement of
the cord, where the pudic nerves are implanted, and the superior
and nobler nervous centres, the intense excitation of even a small
and remote centre is communicated to the others, which as this sub-
sides fall as much below as they have previously been stimulated
above par. The depression is proportional to the previous excite-
ment.

Influenza is a common enough visitant among us, and familiar
though its phenomena be, they seem to me of no little interest.
That a person should be prostrated, as occasionally happens, almost
instantaneously, and remain for some days in profound debility is
surely very remarkable. Without speculating on the nature of the
cause, let us simply consider how it seems to act. There can be I
think no question that the nervous system is the one on which the
stroke especially falls, and as little that the encephalic centres are
prominently affected. The debility is by no means mere muscular
weakness; it is described by Dr. Shapter as " an overwhelming feel-
ing of lassitude and prostration of strength, with in many cases a
loss of all muscular power, together with great anxiety of the pre-
cordia, and agonizing fears of death." The expression of the coun-
tenance is abattu. There are pains in every part, sensations as of
being sore, beat, and bruised all over. Pain in the temples some-
times prevents rest for several nights. Many observers have noticed
the occurrence of neuralgia of the face. Apoplectic and convulsive
attacks have occurred in some instances, in some also delirium, in
others coma. These citations of the experience of others,' coincid-
ing as they do very much with my own, may be considered sufficient
proof that the cerebro-spinal centres are chiefly affected by the
miasma, and that in a paralyzing way.' The catarrhal symptoms
are for the most part such as indicate vaso-motor nerve paralysis,
and atony of the capillary walls rather than actual tissue irritation.
They, as Dr. Watson states, are not so essentially a part of the dis-
order as the peculiar prostration, since they are occasionally absent.
It must appear to every reflecting mind as a very important and
thought-exciting circumstance that there should exist such a subtle,
undetectable poison, or agency, as this of influenza. Standing as it
does quite separate from the exanthemata, it links itself on the one
hand closely with some of our commonest disorders, and on the other
hand manifests no obscure affinity with pestilences, and with that
most widespread of all maladies, malarious fever. ^ The intensity
of its operation on the nervous system, and the fact that it is now

1 V. " Annals of Influenza," Syd. Soc, p. 320.

2 Various good observers, Cleghorn, Petrie, and H. Greenhow, testify to the origin
of re- and intermittent fevers from influenzal aflfection.

86 CEREBRAL PARESIS.

as it were domiciled* among us, makes it important to take count of
it in dealing with a variety of obscure nervous disorders. It is prob-
able that the more we come to know of disease the more we shall
find that there exist a few great distinct morbific causes, which by
acting on diff"erent parts, in different combinations and degrees and
with slight modifications give rise to ever-varying forms of morbid
action.

The treatment of cerebral paresis must essentially consist in the
avoidance or removal of all exciting causes, as well as in the employ-
ment of all means that can recreate and invigorate nerve-power.
The possibility of the paresis being dependent on remote irritation
should be borne in mind. If, however, as is oftenest the case, it is
primary and direct, we must endeavour to act on the enfeebled cen-
tre itself. Among the means at our command pure and bracing air,
generous diet, and healthful mental excitement are perhaps the most
powerful. The influence of the latter is often marvellous ; it is
really curious for any one to observe himself, and note how much
more exertion he is capable of when his mind is thoroughly occupied
and interested, than when the occupation is distasteful. I always
ask my patients who complain of failing power (not of course depen-
dent on organic disease) what recreation they like, and tliat I send
them to, as the best for them. Under the head of food I may allude
to the popular combination of rum and milk as being one of the very
best restoratives that can possibly be given. A daily morning dose
of it to weakly subjects is of great value, and in cases of an acute
kind it may form almost the staple of the nourishment. As to
medicines, our ordinary stimulants and tonics must be employed, the
drug and the dose being matters for consideration in each individual
case. I shall only mention particularly one or two remedies.
Strychnia I have come to regard as a truly valuable cerebral toner, its
action on the encephalic being not far inferior to that which it exerts
on the spinal centres. It is a perfectly safe remedy with due care, and
although I have employed it for years very largely I have never seen
more than slight inconvenience produced by it, when it disagreed
with some patients of unusual susceptibility. It should always be
given in solution, and combines very well with quinine and iron.
Phosphoretted oil I have used occasionally, but it is apt to cause
considerable gastric disorder, and I have had but little encourage-
ment to persevere with it. Dr. Radcliffe has recently spoken highly
of the hypophosphites as remedies for states of nervous depression.
My own experience of them in phthisis would not lead me to expect
much benefit from them. Cod-liver oil is, I think, a remedy of real
value, whether it act according to the chemical view of ministering
to the nutrition of the nervous tissue, or not. An excellent and
rather elegant tonic is a combination of aramon. carb. gr. iv 4- ferri
ammon. citrat. gr. vij-x + tr. nucis vomic. "ix-xv + tr. calumbse
ni^xx -h aq. Si ter die.

CEREBRAL PARESIS. 87

No. 17.— Mrs. P., fet. 48, broad and fat, seen July 24th, 1862. Has
alwa3'S been a weakly-nerved person ; has had ten children. For six or
seven years has suffered with bleeding piles. Her first attack of head
symptoms was in October, 1861, the second in April, 1862. She did not
lose consciousness in either, but had pain at the top of head and backs of
eyes. She recovered from the first attack in six weeks ; from the second she
still suffers. Complains of burning heat at top of head, at times has pain
and great heat of head, the pain is increased by the recumbent position.
Feels some numbness in both hands along the back of the fingers. Has double
vision from paralysis of the right external rectus muscle. Head not tender.
Pulse of good force. Does not feel weak. With strychnia and citrate of
iron and quinine the external rectus regained its power, and I lost sight of
her after October 23d till March 17th, 1863, when she returned to me feel-
ing very weak, languid, and incapable of exertion. A week later the
paralysis of the external rectus was complete. Much hemorrhage had been
going on from the piles. She had great pain at the right posterior part of
head, increased on lying down. The double vision caused her much annoy-
ance from the objects passing her in the streets confusing her. Her piles
were now got rid of by operation, but the hemorrhage from the bowel
continued whenever she had a motion, and the state of the right eye was
unchanged. Nothing could be detected in the rectum to account for the
bleeding except a loose and baggy state of the mucous membrane. This
was at last arrested by tannin taken internally, aided very materially by
removal to the country, where her general health and strength much im-
proved. By the middle of June she had regained a good deal of power
over the external rectus. I urged a return to the country, but this was not
carried out; however, the improvement continued, so that November 10th,
when I last saw her, she had almost perfect power over the formerly
paralyzed muscle. Some bleeding had recurred, but not to any great extent.

Remarks. — This case is an interesting example of a limited paresis of
the nervous centres, involving the origin of one small nerve only. That
the paralysis did not depend on organic disease must I think be admitted
from the beneficial effect of strychnia, iron, and quinine on the first, and of
country air on the second occasion. There can be little doubt that the
long-continued hemorrhage was the cause of the general debility and local
paresis, but it is remarkable that the latter existed before the former was
felt to any notable extent. The pain in the head was probably neuralgic,
yet it was aggravated on lying down. Enemata of krameria infusion, lead
and opium pills, and sulphur internally failed to arrest the bleeding after
the piles had been removed. The case is instructive in various respects, as
showing (1) the connection between debility and paresis; (2) the necessity
for close inquiry into the possible causes of paresis; (3) the superiority in
some instances of a pure air to tonic medicines; (4) the dependence of
hemorrhage in some cases on atony of vessels.

88 SPINAL PARESIS.

CHAPTER VIII.

SPINAL PARESIS.

The nature of this state in general, and its efficient causes have
been sufficiently described in the previous chapter; it only remains
to illustrate its phenomena when it affects a different locality. This
I shall endeavour to do by the relation of some cases, which appear
to me of considerable interest.

No. 18. — C. M., set. 39, butler, ad. Aug. 17th, having been ill five weeks.
He states that his illness came on gradually, apparently from excess in drink-
ing, not in venery. He is paralyzed to a considerable estent in both hands,
so that he cannot dress himself, nor pick up anything. His feet are also
weak and flap down in walking. There is a great if not complete loss of
sensibility in the paralyzed limbs. The paralysis is getting worse. He feels
very weak all over. Head hottish, but there is not much pain in it; he
has never lost consciousness. Tongue coated at back. Bowels costive.
Pulse large, soft Urine of sp. gr. 1014, of good full colour, not albuminous.
Blisters to the neck have been of no service. He was treated with quinine
gr. V ter die, till Sept. 3d, subsequently with ferri et quin citr. gr. x + tr.
nucis vom. ttlx ter die. He improved gradually and was nearly quite re-
covered by December 20th. I have seen him lately, and find he has had no
return of the paralysis during the six years and a half that have elapsed
since he was under my care In some cases it appears as if alcoholic stimuli
taken in excess acted on the spinal centres much in the same way as they
do on the cerebral, impairing and depressing their functional power. Last
year I attended a female, who had been extremely addicted to brandy-drink-
ing for years ; as far as I heard her history she had never had delirium
tremens, but she lost both motor and sensory power to a great extent in
both upper and lower limbs for some months before her death. In her it is
possible that the alcohol had caused sclerosis of the cord, as no remedies
were of any avail.

No. 19 — N. D., aet. 20, m., ad. September 10th, 1858. Ill one month
with inflamed sore-throat, which has got well ; but since then he has begua
to lose the use of his limbs, the legs being the weakest. He can now stand,
but not walk ; the legs are very numb and cold, but he is conscious when
they are touched. He has no pain at all, nor tenderness of the spine.
Sphincters act. Intellect clear. No reflex actions are excited on tickling
the feet. Pupils large and almost motionless. Skin cool. P. natural.
T. white. No cough. Heart-sounds natural. Residence damp. Never
had syphilis. As I could find no clear indication of organic disease of the
nervous centres, I prescribed strychnige gr. -^q, quin. disulph. gr. ij, acid.
s. dil. ^viij, aq. ^i ter die, with ordinary diet and porter. 14th. Feels
much better, has more use of his hands and legs and can walk a little. 17th'

SPINAL PARESIS. 89

Worse last two days. Has now sore-throat and much diarrhoea, with copious
perspirations, and loss of appetite. " Has no use of the hands or legs again."
p. c. mist, et tr. opii Tt^^viij ad. oi- 18th. T. very coated, yellowish. P.
120 full and weak. Some diarrhoea continues. Nausea and headache. Skin
hot and moist. Cannot raise or turn himself in bed. P. c. mist, quater die.
Vini rubri. ^vi in die. 20th. Bad cough. P. 96, full, occasionally inter-
mittent. B. quiet. Adde quince gr. ij. sing, dosis mist. 21st. No sleep from
cough, sputa watery and of a rusty colour. 22d. Feels much better, appe-
tite improving. B. quiet. T. cleaner. No use of limbs. 25th. Galvanism
was applied yesterday with great benefit; he is able to move his hands and
arms much better. Appetite very good. Sleeps well. October 4th. The
legs are now much more weak and numb than the thighs. A much stronger
current required to excite the leg muscles than those of the thigh ; the calf
muscles are greatly wasted. The feet used to be very cold and numb, but
are not now. The hands feel weak and are rather numb, he has "pins and
needles" sensation in them at times. StrychoiEe gr. -^-g, tr. ferri muriat.
n\^sv, acid, hydrochl. TT\^ij, aq. Si ter die. 8th. Can now walk and feed
himself; he cannot bear so strong a current as before. The same treatment
was continued till the end of November, when he was discharged with only a
slight degree of weakness remaining in the legs, which was referred to the
knees. It seemed that the extensor muscles of the thighs had not regained
their full power; he was able however to walk very well, and his arms had
become quite strong. The dose of strychnia was gradually increased to gr.
^ ter die.

A curious circumstance observed by himself was that his feet swelled
during the night, so that he could not get his boots on in the morning,
but after walking about the ward a little the swelling subsided. His
urine was free from albumen and was otherwise healthy, except that
at one time during the catarrhal affection it deposited much uric acid.
I cannot but regard this as a very proving case. A man is admitted
■with incomplete paralysis consecutive (as he reports) to catarrh, after
improvement has commenced he relapses, and becomes considerably
more paralytic than at first, while simultaneously he is affected with
asthenic bronchial and gastro-intestinal catarrh. Under a persistent
tonic treatment he makes a good recovery. It seems impossible not
to recognize in such a case as this the operation of a depressing mi-
asm (influenza), acting with unusual potency on the "whole nervous
system. There is no indication of the paralysis being other than
primary and direct, or that it is in any way attributable to remote
irritation. The phenomena of vaso-motor paralysis were well marked
in the skin and the mucous membranes, and the nocturnal swelling
of the feet v^sls owing, I believe, to the same condition. . Is it con-
ceivable that the vessels of the nervous centres were in a state of
spasm, and that the paralysis depended on anaemia ? What would
have been the result of treating this case in the same way as the
one recorded by Ollivier, v. p. 73 ?

No. 20. — A. W., female, set. 9, has had paraplegia last three months, it
increased rapidly after it commenced, and in fourteen days was as bad as

90 SPINAL PARESIS.

it is now. She cannot stand or walk, but can move her legs as she sits.
There is no loss of sensation in the lower limbs, they have wasted consid-
erably. The muscles of the lower limbs are very insensitive to the interrupted
current, more particularly the extensors. The spine is much curved, convex
backwards and to the right side. When the legs first became weak she had
more constant pain in back, but it did not seem to be increased by friction.
Beginning from the two lower dorsal vertebrae there is tenderness on press-
ing the spinous processes all the way down to the sacrum. No sign of any
tumour in front of abdomen or thighs, no trace of any abscess. At times
she has constrictive sensations in the abdomen. The legs have been painful
and aching lately, they start sometimes. Urine pale, aqueous, sp. gr. 1016,
not albuminous, often thick and offensive, is passed in small quantities and
with discomfort. It deposits phosphatic crystals, consisting of aciculae united
in stellar groups. B. very costive, only opened by enemata, motions very
dark and hard, when the b. act has much pain in lower abdomen and all
over her. After a dose of aperient medicine the legs have often appeared
weaker. Appetite always poor, capricious, aversion for meat. Had constant
nausea when her legs began to fail, but this is less now, is most felt in
mornings. The last six weeks has complained of constant pain in the foi'e-
head, and all over the head. Sleeps badly. R. Strychn. gr. ^2-, ferri et
quin. citr. gr. v, aq. ^ss ter die. R. 01. morrh. 3i ^^'^ die. The limbs
to be faradized daily. This was continued for a month, to October 80th,
without any advantage, inr)(9ed she was reported altogether worse. The cir-
culation was very feeble, the legs hypersensitive. R. Liq. cinch, flav. rTL40,
pot. iod. gr. xxxv, ammon. carb. gr. xxv, tr. bellad. n^ 80, aq. ^ vi. M.
iss ter die. Vini aloes 5ss p. r. n. Empls. bellad. 3x6, spinse dolenti.
November 24th. The belladonna disordered her vision, and did no good,
the plaster was worn for a time, but caused discomfort and was left off.
The other remedies have been continued, the dose of bark and ammonia
being increased, and infus. chirett. substituted for the water. The aloetic .
wine moved the bowels well for a time, but even 5i doses fail now; it pro-
duced no depression like all other purgatives. The faradization has been
continued, and the muscles of the leg as well as of the thigh are much more
lively, acting briskly to the current. She cannot stand, but wriggles her-
self about pretty actively on her knees. The back appears much straighter
than it used to be, she can at any rate sit quite upright without showing
any deformity. There is still local tenderness in the lumbar spines as tested
by pressure, or applying a hot sponge. She has also pain in the front of
abdomen, on both sides, and all about it, but does not make her wince under
steady pressure. Feels still very cold. She is much more active mentally,
amuses herself one way or the other all day long. Pt. To have warm wine
at night, and rum and milk in the morning. December 8th. Better, can walk
from chair to chair leaning on her hands. Very pale. Is so pleased to be
able to get about that there is risk of her over-exerting herself. 23d. After
a relapse for a few days lately of debility and languor she has again improved
so much that she now walks alone quite well, goes all round the room, and
even up stairs, though she halts on the right leg. She says she has nothing
like so much pain in the back as she used, she bears pressure on the spine
much better. Appetite very poor still. Taking tr. cinch, flavse 3i t<ir die,
and strychnias gr. -^^ bis die, with rennet wine at meals. B. are comfortably
moved by syrup, rhamni cathart., one day they acted of themselves, which
thej have not done for months. January 6th. Can now walk about very

SPINAL PARESIS. 91

well, but is soon tired. The mornings are her worst time, always complains
then of being tired and languid. Sleeps and eats better. B. open without
medicine. Feb. loth Has not made any distinct progress since, a fortnight
ago had a relapse, which took her oflf her legs, and was attended with pain
in her back and side, and sleeplessness. Has palpitations sometimes severe.
P. good. Urine very thick and offensive last week, clear and natural now.
Is extremely nervous and sensitive at night, has great difficulty in getting
to sleep, is alarmed and trembles at every sound. _ Has had cold dashing
every morning. B. in good order. F. + Q , citr. c. tr. nuc. vom. ter die.
P. c oleo. To be much in the open air in a vehicle. March 12th. Has
not been much out; one day after being in the open air about twenty min-
utes she became almo'st insensible and could hardly speak. Is now better
again, and pretty active on her legs in the house. The strychnia and bark
have been resumed. R. Steel wine Ji '^^'^ <^^^- 17th. Has been moved to
the country, has a better appetite last two days than she has had for a year,
and sleeps beautifully. Walked yesterday three-quarters of an hour with-
out fatigue. April 15th. Is looking much better and is in all respects much
improved. Still she has not the free action of her legs that she ought to
have, if she trips in walking she feels it in her back. September 1st. Has
been again in the country for two or three months, latterly at Margate.
She runs about for hours without being fatigued, and is altogether a different
being to what she was. Still a little over-fatigue, especially in the sun, has
a great effect upon her.

This case contrasts in several points with the preceding, although
I believe the pathological condition was almost identical. The cause
in the first case was a miasm acting upon an average system. In
the second there was none to be traced, except it be admitted that
some might have been generated from some broken-up clayey ground
near the house where building was in progress. Solitary vice was
of course suspected, but I believe there was no ground for the suspi-
cion. The " grundleiden" seems to have been a most feeble state
of the nervous centres especially of the cord, which was constantly
lapsing into exhaustion, and which required persevering tonic treat-
ment not only by drugs, but by pure air, and all that could recruit
the feeble power. The excessive hypersesthesia was both a product
of the debility, and reacted on it and increased it, v. p. 44. In the
first case there was little difiiculty in forming at once the diagnosis
of functional paralysis ; in the second I felt considerable doubt for a
long time. The chief circumstance that weighed with me in regard-
ing the disorder as functional was the presence of such marked signs
of general debility and hyperaesthesia. Had these been absent, I
should have been much inclined to set down the case as one of organic
disease. The local tenderness of the spine, the constrictive sensa-
tions, the phasphatic urine, and the paralysis were formidable symp-
toms, and might well have proceeded from chronic inflammation of
the cord with softening. The insusceptibility of the muscles to the
interrupted current was rather a favourable circumstance than other-
wise; had the reverse been the case, it would have made the existence
of actual central change much more probable. The progress of the

92 SPINAL PARESIS.

case was by no means plain sailing, the tendency to relapse from
imperceptible causes was very marked, and nothing but steady per-
severance carried us through. In all such cases it is wise to follow
Dr. De Ricci's example,^ and refuse to undertake the responsibility
unless the friends consent to give one fair play.

It appears to me a very important question in regard to such
states as the above, whether what was originally functional may not
by long continuance pass into actual organic disease. Obviously it
must be almost impossible to ascertain this certainly ; analogies
might be adduced both for and against its occurrence. I think the
conversion of the one state into the other by no' means impossible,
and I feel assured that no time should ever be lost in adopting effec-
tual treatment for the restoration of functional power. The experi-
ence of physicians in cases of what is termed infantile paralysis is
strongly to the same effect; my own observation quite confirms the
truth of Dr. West's remark as to the importance of early treatment.
Though it is very possible that paralytic affections occurring in chil-
dren, and much resembling one another, may originate in different
pathological conditions, as Dr. Heine has lately asserted, yet I think
the absence of signs of inflammation of the cord or brain, or their
membranes, the existence of more or less debility and disorder of
health, the non-progressive character of the disease, and especially
the "juvantia," will not leave us long in doubt whether we have to
deal with a paresis or any organic aff"ection.

No, 21. — J. Gr., £et. 3 years, male, admitted Feb. 23d, having been ill
three weeks. He has lost the use of his limbs, can move his feet, but not
stand, or walk. The power of the arms is somewhat impaired also. Appe-
tite bad. The palsy came on in the night; the child was quite well on going
to bed; in the morning bis mother found his legs quite palsied, the arms to
a less extent, and the face drawn to one side ; this last symptom lasted only
a few hours. Steel wine was given for fourteen days without benefit, and
aftervyards ferri et quin. cit. -f tr. nue. vom. Turpentine liniment was
applied to the back and legs. April 4th. He is able to stand and walk
round a table, holding by it. The improvement was soon after interrupted
by his having got some wrong medicine, and then by an attack of dysenteric
diarrhoea, so that on April 22d, when the tonic was resumed, he had lost the
power of standing. After this, however, he went on steadily to recovery,
and in the beginning of July he had gone to school. The disorder in this
case at first was somewhat extensive, involving not only the nerves of the
upper extremities, but one of the facial. It soon however subsided in the
higher parts of the spinal centre, and confined itself to the lower. Under
tonic treatment it disappeared, after a temporary interruption by some debili-
tating circumstances. Clearly this is not the history of any organic disease.
The tendency of the kind of paralysis we are considering to supervene during
the night is quite a feature that belongs to the family of neuroses, v. p. 44.

No. 22. — L. S., JBt. 2| years, f., ad. February 11th 111 three months.
Has lost the power of walking all that time, cannot now even stand alone ;

» Dublin Med. J., Aug. 1862.

SPINAL PARESIS. 93

but can move her legs, which are not wasted nor cold. The paresis came
on suddenly one day, she never had a fit. No pain in spine, nor distortion.
No injury to the back at any time. Sphincters act. Has nearly all her
teeth. Looks healthy. Some vaginal discharge. Strychnia was given till
March 3d, the dose being raised from gr. ^V to gr. -go bis die, and ol. morrh.
3i ter die. given also. In a fortnight she was able to toddle round a chair
holding by it, in another week she could just walk alone. Citrate of iron
and quinine was then substituted for the strychnia gr. iv ter die, and in
fourteen days she could walk across the room and pick up anything from the
floor, though her gait was very straddling.

No. 23. — E. C, set. 2, m., ad. Feb. 4th. Ill four months, became gradu-
ally worse; has lost the power of walking; bends forwards in sitting, cannot
hold himself up. His legs tremble so that he cannot stand well. Arms all
right. Has pain at lower abdomen, bowels loose, motions oflFensive, is thirsty,
appetite bad, has lost flesh. Sleeps well. Has all his teeth but the last
molars. Head distorted since birth, right forehead bulging, left eyelid droops.
Never had fits. He was ordered ferri et quin. citrat. gr iij ter die, a grain
of Gray and of Dover's powder o. n. for three nights, and subsequently a
little tr. opii was added to the mixtui-e. 01. morrh. was given besides.
March 21st. The report is that he is getting on nicely, is a great deal better,
runs about. April 4th. Improvement continues.

No. 24. — W. W., 9et. 2h, m., ad. Feb. 8th. Ill li year, unable to move
the right arm and leg properly all that time, no material wasting of arm,
halts in walking on the right leg; can walk a little, but often falls. Health
now good. Had a fit for 2\ hours when \\ year old, when he was cutting
two molars, and has had the paralysis ever since. His health was affected,
at the same time he was languid and weakly. He was ordered cod oil and
iodide of iron, which he continued till March 14th, when citrate of iron
and quinine was given in place of the iodide. On 24th the report is that
he is doing nicely, gets quite strong on his legs, can use his hand.

Remarks. — In these four cases the palsy came on without apparent
cause in three, in the last it succeeded to a fit. In all I think it may be
fairly argued that no material damage had occurred in the centres. That
the palsy was not of refles origin I think certain, both from the absence of
any cause of irritation as well as from the "juvantia." Had the vessels of
the centres been in a state of anaemiating spasm, as Brown-Sequard assumes,
would not the starved tissue have certainly degenerated and gone into white
softening in cases of such long standing as Nos. 22, 23, 24 ?

When one limb only is affected it may not be always easy to form
an opinion whether the disorder is seated in the cord, or in the
nerves of the part, especially if one or two nerves only are involved.
In proportion to the extent of the paralysis is the probability that
the disease is central.

The following case affords an instance of some uncertainty in the
diagnosis of the exact seat of morbid action : —

No. 25. — M., set. 56, m., seen April 2, 1861, having been ill fourteen
days since exposure to cold. He had a catarrhal affection when the pa-
ralysis came on. He suffers with wearying, aching, dragging pain about

94 SPINAL PARESIS.

the right shoulder, with loss of power in its abductor muscles. The arm
bangs closely by the side of the body, and cannot be raised or abducted
except by a jerk of the body. The deltoid and trapezius and other muscles
about the shoulder are not wasted, but are more excitable and sensitive to
the interrupted current than those of the opposite side ; a moderate current
causes much pain in these parts, and well-marked contraction of the deltoid
especially. Two years ago he had similar enfeeblement of the right shoul-
der, but not nearly to the same extent as at present; it lasted nine months.
This morning he could not feed himself with a spoon, nor tie his cravat,
nor put on his coat. His vision fails at times, and he has had other signs
of disordered nerve-action, as tremblings, twitchings, &c. He is very weak
and thin. Skin warm. P. good. Urine used to be very thick; last three
weeks it has been clear and of good colour. R. Ammonio-citrate of iron,
carbonate of ammonia, tinct. of nux vomica, and infusion of calumba thrice
daily ; the shoulder to be rubbed daily with compound camphor liniment,
and to be faradized. April 8th. General state improved, that of shoulder
not much. A spot about the size of a shilling near the acromion is ex-
tremely sensitive to the current. R. Strychniae gr. j^ -f tr. cinchon. 5i
ter die. 17th. Is decidedly improved, can abduct the arm to some extent.
May 13th. Is quite recovered, and has full use of the arm. At times
he has felt sensations in his legs of weakness and semi-paralysis.

Remarks. — Had there not been some indications of failing nerve-power
in other parts besides that principally affected, as in the nerves of the eyes
and lower limbs, I should have felt much uncertainty as to whether the
circumflex nerve alone was affected in some part of its course, or whether
the disorder was central. The latter opinion, I have no doubt, is correct.

The nature of paresis, cerebral or spinal, is, I think, somewhat
elucidated by reflecting on the condition of a nerve, such as the
median or ulnar when affected with severe neuralgia. The func-
tion of the nerve is temporarily abolished, the skin which it supplies
is utterly ansesthetic, and the muscles palsied. Under the influ-
ence of quinine and perhaps galvanism the sensory and motor power
is restored. It is certain that these remedies would not amend a
state of neuritis; and I can see no other view to adopt than that,
owing probably to some minute molecular derangement of their tissue
depending on impaired nutrition, the nerve-fibres are no longer ca-
pable of conveying centrad and peripherad the impressions they
normally transmit. There is no difficulty in considering that the
white fibres of the brain and cord may fall into a like state as those
of the nerves, in which case the result would be the same as in peri-
pheral neuralgia. The cells of the gray matter may probably be
affected in the same way as the tubules, whose axis cylinders are
continuous with their interior. This I am inclined to think is espe-
cially the case when the paralysis appears to be the result of a
morbid impression (as cold and wet) made on the sensory surface
of the skin. The following is an instance of this kind.

No. 26. — J. Gr., aet. 45, ad. Feb. 11th, ill two days. Has usually good
health, does not admit drinking habits, but there is some doubt about this.

SPINAL PARESIS. 95

Is much exposed to wet in following sportsmen. He got very wet before
tbe present attack, which came on suddenly; he was unconscious at first
for a few minutes. He is now very giddy, and so weak on his legs that he
can barely stand alone, and was brought to the hospital in a cab. Head
rather hot, not painful, aching pains in neck and shoulders. Right hand
is closed, he cannot extend the fingers, it feels numb. T. clean. P. soft.
No strength, no appetite, no sleep at night. Bark and ammonia with vale-
rian were given, and after ten days, two grains of opium o. n. March 7th.
Able to walk to hospital, right hand numb and crampy. 28th. Arm gal-
vanized three times without benefit. April 4th. Quinine and iron ordered.
18th. He improves, but states that his arm has been better every other
day for the last week. May 2Sth. He can now carry a large basin and
jug filled with water. July 4th. Getting on well.

T have recorded another case {v. Brit.- ]\^ed. J., April 16, 1859),
in which symptoms of paralysis with impairment and disorder of
sensation appeared in a young man the day after he had been stand-
ing a long time in wet grass. The paralysis without being complete
was remarkably extensive and diffuse, affecting not only the arms
and legs, but the masticatory and ocular muscles. Death occurred
in about a week from asthenia. Nothing was found in the autopsy
in the brain or cord that accounted for the phenomena, nor did mi-
croscopic examination discover any exudation cells, any granular
coating of the minute vessels, or any indication of structural change.
In cases of this kind it seems that the nerve-cells of the cord, as the
first recipients of the morbid impressions, have their nutrition in
some way disordered, in consequence of which their functional power
fails. Graves, in bis lecture on paraplegia, records cases where the
disease was induced apparently by exposure to cold and wet, and in
which it came on gradually, though with very varying rapidity in
different instances ; some being rendered almost completely para-
plegic in a few weeks, others not for months or years. He finds
stimulating liniments, and blisters applied to the parts of the affected
limbs most copiously supplied with nerves, the most effectual means
conjoined with the administration of strychnia and sulphur internally.
He records one case in which a very careful autopsy discovered no
diseased condition of any organ.

The conditions above noticed embrace the most frequently occur-
ring forms of paralysis of the cord not dependent upon organic dis-
ease. Reflex paralysis appears to me to be a much rarer affection.
I have not met myself with an instance of it. As there appears
some tendency to use the term rather loosely, I will repeat that it
seems to me properly to belong only to cases where the paralysis is
evidently dependent on a persistent irritation, increasing when this
is increased, and vice versa. It is characteristic of true reflex para-
lysis that removal of the irritation proves curative, while all other
means fail. It is certain that no true case of reflex paralysis would
be benefited by strychnia, or galvanic excitation of the nerves or
muscles of the affected part, nor by stimulating applications to the

96 SPINAL PARESIS.

cutaneous surface. These are appropriate to the paretic state, and
form by their success a good test of its presence.

There is another group of instances, which are not very uncommon,
but the pathology of which is very obscure, and which I allude to
without by any means affirming that they truly belong to the class
of paresis. The following is an example : —

No. 27. — E. S., female, set. 7J, seen Aug. 2, 1861. A month ago be-
came feverish ; her head or rather her neck was stiif. She bad been treated
for rheumatic fever, but does not seem to have had inflamed joints; the
urine has deposited a thick whit}' sediment. Her legs became weak at once ;
after two days she had quite lost the use of them; the left arm was affected
similarly a little before the legs, and remains so. She was delirious at first
and had pain at the top and back of the head, which has ceased. For four-
teen days she could not sleep at night for restlessness, sleeps now. There is
no loss of sensation in the legs, but rather pain, she cries out when her
calves are touched. No tenderness in spine. The muscles of all the para-
lyzed parts are very insusceptible to the interrupted current. She is quite
unable to stand. Functions in tolerable order. I prescribed strychniae gr.
50 + ferri et quin. citr. gr. vi, aq. §ss ter die; the dose of strychnia was
afterwards increased to gr. ^q, and the limbs were occasionally faradized.
Oct. 5th. Is decidedly improved, can stand. The right leg is far the
worst, and its muscles are insensible to the current, but the skin is hyper-
sesthetic, more so than it used to be. The left arm remains very useless;
she has no power or but little over the flexors. Some stiffness in the mus-
cles of the jaws from the strychnia. March 28th, 1862. Is decidedly im-
proved, moves about actively, but the left hand and arm are still deformed,
the hand drawn back on the forearm; she can however hold things with
it. Dec. 31st, 1862. Walks about well, has walked some miles in a day,
but halts still on the right leg. The flexors of the left hand are deficient
in power, though she can use the hand tolerably. No medicine taken the
last year.

The first question here for consideration is whether the disease
was essentially acute rheumatism, attacking the cord. I am quite
aware that rheumatism may appear primarily in the heart, but I
doubt whether it is ever confined to this or any other internal organ,
without sooner or later manifesting articular symptoms. There must
evidently have been some resemblance to acute rheumatism in the
febrile attack to have induced the attending practitioner to make
this diagnosis. It is not easy to regard the disease simply as mye-
litis. The delirium, the very early supervention of paralysis affect-
ing the cord as high as the origin of the brachial nerves, the absence
of spinal tenderness when I first saw her, and as far as appears from
the commencement, the preservation of sensibility, and the "juvantia"
seem to me to afford evidence against viewing the disorder as mye-
litis or meningitis.

It is a highly important point to which Dr. Gull has drawn atten-
tion that lesions of the cord are occasionally attended with an affec-
tion, which in many respects is closely similar to acute rheumatism.

SPINAL PARESIS. 97

The explanation of this probably is that the vaso-motor nerves of the
whole system are paralyzed, and that in consequence pyrexia is set up.
Case 27 recorded by this physician' is of very high interest. The
patient, a -widow working hard at a inangle, had for two years, when
exerting herself much, felt pain in the back between the shoulders,
and a sense of constriction and coldness round the chest. Ten days
before admission she was seized with pain in the left leg, and spas-
modic contraction of the muscles, with increase of the pain and con-
striction of the chest. She could extend the leg, but not walk. The
next day there was febrile heat and diarrhoea, the hands, knees, and
ankles were swollen and painful. A slough formed on the sacrum.
On admission the hands were swollen, stiff, and painful with some
erythema. The legs were so far paralyzed that she could only move
them very feebly and slowly ; the muscles very wasted, but retained
their electro-contractility. Sphincters weak. Sensation nearly
normal, but at times both legs felt numb, and were drawn up involun-
tarily. Touching the feet gave rise to formication and to very lively
excito-motor movements. Eight days after admission the hands were
still swollen and erythematous, the face flushed. Pulse 100, full.
Perspiration had an acid smell. • Pupils large. Nights sleepless.
Urine ammoniacal. Opii, gr. i Qtis horis. Wine 6 oz. daily and a
chop. Under this treatment with faradization of the limbs she com-
pletely recovered in about six months. This case seems to me to
have been essentially one of paresis of the cord with implication of
the vaso-motor fibrils. The history is wholly that of nervous ex-
haustion, the symptoms are not contradictory (no pain or tenderness
on pressure of the spine), and the "juvantia" are entirely corrobora-
tive of this view. The state of the urine and the good effect of the
opium afford some tolerable evidence that the disease was au fond
different from acute rheumatism. The occurrence of a slouo-h on
the sacrum in the existing condition of the vascular system is pretty
good evidence, that the local death was not dependent on arterial
constriction and ansemia as Brown- Sdquard supposes it to be. It is
much more probable that the impairment of nervous influence left
the integument so enfeebled in its vital qualities that it was unable
to resist the injurious influence of pressure. On careful considera-
tion it appears to me highly probable that the case I have above re-
corded was essentially similar to Dr. Gull's, the quasi-rheumatic
disorder in each being produced in the same way. In my case
however the cause of the affection was probably some obscure influ-
enzal or malarious miasm acting on a weakly nervous system. The
child resided in one of the outskirts of London, where house-building
was in progress, a kind of locality which I have often observed to
be favourable to the generation of such influences. The long per-
sistence of the paralysis suggests its dependence on some organic

» "Guy's Hospital Reports," 1858, p. 127.

98 SPINAL PARESIS.

lesion, but this is opposed by the decidedly good effect of tonic treat-
ment, though it was by no means effectually carried out.

Diphtherial paralysis is very evidently a paresis. From its prone-
ness to extend so widely over the nervous system, affecting not only
nerves of motion, but those of common and even special sensation,
it seems most probably to be a central affection. This is also infer-
rible from its being generally, if not invariably, bilateral. It is
stated by Dr. H. Greenhow that diphtheric paralysis at its outset is
peripheral, extending gradually upwards from the tips of the fingers
and toes towards the trunk. This certainly is the usual description
of what is termed peripheral paralysis (as distinct from a central
affection), but it is obvious that it by no means implies that the
extremities of the nerves are first affected, and that the morbid
action gradually advances centrad to the cord. It really means
that one set of nerves is affected after another, leaving it entirely
an open question whether the nerve-roots are the seat of the disorder
or the distal extremities. It is clear that the same phenomena
would ensue if we suppose the morbid action to be located in the
cord and to proceed gradually upwards from below. The view of
the paretic nature of diphtherial paralysis is strengthened by the
occurrence of similar paralysis after typhus in which, as Leudet
affirms,' there is an absence of any morbid change in the brain or
spinal cord. As far as I can find it does not appear that any
organic change has been discovered in the nervous centres in fatal
cases of diphtheric paralysis. The only exception is a case recorded
by Mr. Humphry,^ who found in one case a small suppurated spot
with softening of the adjacent brain substance in the superficial part
of the left cerebral hemisphere. Hemiplegia of the right side had
been present, but had gradually disappeared. The connection of
this lesion with the paralysis seems open to some question. Perhaps
the strongest argument in favour of the paretic nature of the paraly-
sis in question is the good result of a highly tonic treatment, which
we shall presently notice.

The interval which most observers have found to occur between
the cessation of the primary disorder and the supervention of paraly-
sis is an important point for observation, as remarked by Dr. Green-
how, since it tends to show that the nerve affection is not attributable
either to albuminuria or to anaemia. It seems also as if it could
hardly be the result of the original poison or influence, as no indica-
tions of it appear while the action of the latter is in its full inten-
sity. In this respect it resembles the renal sequelse of scarlatina,
which sometimes ensue at a period when convalescence has decidedly
commenced. As numerous cases of even severe diphtheria recover
without any paralysis it follows either that some special modification
of the original poison must be generated in the system ; or, what is

' " Gaz. de Paris," 19, 1861. 2 "Brit. Med. J.," July 4, 1863.

SPINAL PARESIS. 99

more probable, that a certain peculiar state of tbe nerve-centres is
requisite to allow them to be rendered paretic by the poison. This
state may be gradually induced dui-ing the progress of the disease.
The opinion expressed by Gull with regard to typhus fever,^ that
elimination of the poison from the system by no means coincides with
convalescence, seems to be verified also in the case of diphtheric
paralysis. The basis of this view is a due appreciation of the impor-
tance of the vital state of the solids with reference to their liability
to be affected by poisons. It is by no means necessary that the
presence of a poison in the blood should evoke phenomena of disease ;
the latter may not ensue or may cease because the tissues either are,
or have become inapt to be affected. This is a most material point
for the practitioner, who often has no power to prevent the entrance
or the stay of a poison in the system, but who may do much to
render the system tolerant of it. V. a paper on the theory of eli-
mination in the treatment of disease, Brit. Med. J., April 24th,
May 1st, 1858.

The treatment of diphtheric paralysis is wholly that of a paretic
affection, and may stand for that of spinal paresis. This at least
expresses the general opinion of those who have had experience.
Wade is the only writer who finds more advantage from pot. iodid.,
ferri iod., and hyd. bichlor,, than from strychnia, quinine, and iron.
These, and especially the first, are the remedies to which I should
always have resort, together with ol. morrh., a pure air, and a gen-
erous diet. The dose of strychnia may possibly require to be in-
creased in some cases rather largely. I should not abandon its use
in any refractory case, where the diagnosis of paresis was certain,
until I had carried it to the extent of producing slightly its physi-
ological effects. Dr. Bardsley^ gave it in some cases of paralysis
to the enormous amount of a grain and a half daily. Sulphuret of
potassium baths have proved useful in this kind of paralysis, as well
as in various kindred affections. This affords an instructive exam-
ple of the beneficial effects of suitable stimulation of the sensory
nerves of the general cutaneous surface. Although the effect pro-
duced on any one part is small, yet the total impression conveyed to
the nervous centres is considerable, and probably by its mildness and
general diffusion acts with great advantage. Dr. Copland relates a
case of general motor paralysis removed after other means had failed
by frequent recourse to warm baths containing stimulant substances.
In one case of paraplegia under my care lamp baths and the cold
douche to the spine had been of benefit. These remedial actions
are just the opposite to the morbific inhibitory, but in both the same
principle is involved, viz., that of affecting nervous centres through
afferent or excitor nerves ; the result in the one case being to de-
press, in the other to arouse the functional energy. Everything
depends on the kind of impression made, and on the vital state of

' "Med. T. and Gaz.," April 5, 1862. 2 Hospital Facts and Observations

100 CEREBRAL EXCITEMENT.

the nervous centre. The virtues of pine-leaf mud baths, and those _
made with the contents of ruminants' stomachs, are to be accounted
for in the same way. The following is a well-marked case of diph-
theric paralysis. ^

No. 26.— H. W., m., set. 11, ad. April 23d. Ill two months. Has had
severe attack of diphtheria, followed by violent sickness, albuminuria, ascites,
and lastly the symptoms of paralysis of the soft palate and extremities.
Liquids are apt to return through his nose when he tries to swallow. His
arms are very weak, but not quite paralyzed. The legs are very useless, he
cannot stand, and has very little sensation in them. His vision is affected,
he cannot see near things well. The paraplegia has come on the last three
weeks. The sickness has subsided. Three children and the mother of the
family were attacked and one died. Ordered strychniae gr. 3^^, ferri sulph.
gr. ij, spt. Eeth. s. co. vix, aq. ^ss ier die, et ol. morrh. Ji ^^^ ^'^•
Lin. terebinth, dorso. The dose of strychnia was gradually raised to gr. ^'^,
and he was almost quite well by the end of June.

CHAPTER IX.

CEREBRAL EXCITEMENT.

This state is of course the opposite to paresis. The functional en-
ergy of the various encephalic centres is aroused, and shows itself by
corresponding phenomena. Perhaps the stimulating influence of
good wine, not of course its intoxicating, affords as good an example
as we can have. The face is somewhat flushed, and the brain we may
believe is too, the eye is bright, the flow of ideas is rapid, the tongue
eloquent, the temper cheerful, and the spirits elated. Of the same
kind, though altogether unnatural and infallibly pernicious, are the
stimulating effects of opium. Cocoa, except in large doses, produces
less intoxication, and its use is not followed by depression. All
physical agents are however surpassed by intense mental excite-
ment. Not to mention acute mania, the maternal instinct does un-
questionably develop an extraordinary amount of energy and endur-
ance in the weaker sex, sometimes overpassing it may be affirmed
anything shown by the stronger. A mother will watch by her
child's sick bed for days and nights together, till one marvels how
it is that nature does not sink under the effort. In a milder degree
mental stimulus shows its energizing influence in enabling us to
endure fatigue to a much greater extent than we could do without
it. A sportsman will keep on foot for many hours in pursuit of
game who would declare himself " dead beat'' with half as long
a constitutional. The following story is so beautiful that I cannot

CEREBRAL EXCITEMENT. 101

forbear quoting it.^ "After the crossing of the Green River the
whole party went on foot, and the men were becoming weaker every
day for want of food. The painter who had one foot badly frozen
became at last through lameness constantly the last man on the
trail, and once his energy almost deserted him. He was at the top
of a mountain of snow with not a tree to be seen for many miles.
Night was approaching, and in the direction taken by his comrades
not a sign of life could be descried. He sank exhausted on the snow
bank, and took out of his pocket for a farewell look the miniatures
of his wife and children. Power came to him out of their faces.
He thought how little his wife could afford to be a widow, or his
children to be fathotdess, beat down his despair and struggled for-
ward. It was not till late at night that he arrived at the camp
fire."

The effect of cerebral excitement varies extremely according to the
previous condition of the organ. A strong well-balanced brain will
bear a great deal of excitation without showing any irregular or vio-
lent reaction, or subsequent debility; while a weak and excitable one
will be provoked by a less amount of stimulation to manifest phe-
nomena of morbid activity, and will fall subsequently into great col-
lapse. It is just in the difference of capacity for enduring the wear
and tear of excitement that original endowment and training show
the greatest influence. One man will sleep soundly and digest well
under the same anxiety which renders another wakeful and dyspeptic.
It is related that the Iron Duke, on the eve of an engagement, was
aroused during the night from his sleep by a message that some
important point was seriously menaced. Having reflected for a
moment he pronounced it erroneous, and turned off to sleep again.
He was right, but few men could have composed their brain to sleep
after such an awaking, even though they Avere persuaded that the
alarm was groundless. In these days of feeble and sensitive nervous
systems it seems to me to be one of the most important parts of edu-
cation to develop by physical and moral training a robust and non-
excitable state of brain, so that the individual may be well able to
confront the strain and struggle of actual life. It is in not affording
this robust vigour but generating hypersesthesia instead that tender
nurture becomes often positive cruelty.

The morbid states characterized by cerebral excitement are chiefly
those in which delirium is a conspicuous feature. Quiet muttering
delirium tending towards coma may be left out of account. Active
delirium, sthenic and asthenic, and the so called delirium tremens,
are the states we propose to examine. Sthenic delirium is a common
result of meningitis, and of ardent, and of other high fjevers. The
gray matter in such cases is usually found after death of a darker
colour than normal, and sometimes especially in young persons is
distinctly reddened. The white substance exhibits numerous bloody

1 Household Words, March, 1857, p. 264.

102 CEREBRAL EXCITEMENT.

puncta. There can be no doubt however that fierce delirium may
occur when there is no remarkable vascular injection, at least when
no traces of this are found after death. In fact in this as in a
multitude of similar instances the excitation of the tissue is the pri-
mary change, and the vascular repletion is secondary and varying.
If the normal tissue activity be great, though the gray matter will
probably be dark, yet there will be no effusion of lymph, and no
material capillary engorgement. If however the functional power
of the tissue fails, and an inflammatory condition commences, we
shall have considerable vascular repletion, and probably more or less
exudation, which however may not extend beyond mere coating of
the vessels with granular deposit. There is na inconsiderable ana-
logy between a diarrhoeal or a salivary flux, and active delirium. In
both extensive tracts of cell-growtl} are stimulated to an excessive
and rapid nutrition, which interferes with the due development of
the individual particles. In the former instance the cells being dis-
posed on a free surface are shed rapidly ; in the latter we are unac-
quainted with the precise changes which the cells undergo. Assum-
ing the correctness of the general opinion, that the axis cylinders of
the nerve-fibres are continuous with the granular interior of the
nerve-cells, it seems almost a necessary consequence that disordered
and hurried nutrition of the latter would communicate itself to the
axis cylinders, and so give rise to abnormal sensations, and disorderly
motor impulses. The very varying amount of cerebral excitement
in diff'erent instances of the same kind of fever must be admitted
to depend in part on corresponding diff"erences in the quality of the
nervous power. The poisons are doubtless the same in all cases,
but the condition of the recipients may vary greatly. Of course
much will also depend on whether the poison be specially determined
to the head or not.

It is not yet fully determined what changes occur in the urine in
cases of sthenic delirium. In meningitis and acute mania it is
probable that the phosphoric acid is much increased, but this is not
yet fully established. It would be highly desirable if we had some
trustworthy indication, from this or from any other source, to guide
us as to the existence of really sthenic delirium in any given case,
but we fear we have none such at present, and that we must rely in
this as in many other instances on our discriminative tact. Of
course if a patient has a flushed face, and hot head, a firm not very
frequent pulse, a ferrety eye, a contracted pupil, and shows consid-
erable muscular power and energetic action there is no room for
doubt; but in such a case as that recorded by Graves (v. Qlin. Med.,
p. 175), where the patient, though violently delirious and unmanage-
able, "on the borders of frantic madness," had a pulse almost
uncountable from quickness and exceedingly weak, with cold extremi-
ties, the most experienced would hesitate as to the proper means to
be adopted. Graves says, a very few leeches would kill him, blisters
would be too slow in their action, and might even aggravate the

CEREBRAL EXCITEMENT. 103

disease, cold affusion seemed inadmissible. Yet this man took in
less than forty-eight hours 12 grains of tartar emetic without any
prostration being produced, while the cerebral excitement was calmed,
sleep induced, and the pulse rendered slower, and much softer and
fuller. A right discrimination in such emergencies as this is indeed
a high attainment, the more so as the remedy is quite capable of
being very pernicious as well as beneficial.

Active delirium in rheumatic fever is in the great majority of
cases the result of an increased excitability of the nervous tissue,
and is not dependent on inflammatory movement. In the cases re-
ferred to by Dr. Fuller where actual meningitis had occurred the
delirium had been rather of a low kind. Dr. Copland distinguishes
two sets of cases, one where delirium or mental disorder occurs in
the course of acute rheumatism, without any abatement, or but little
either of the fever, or of the local disease. In these cases, he says,
the head aifection is chiefly nervous, and contingent upon the febrile
condition, in connection with depression of nervous or vital power.
In the other, the head symptoms appear at an advanced stage of
acute or sub-acute rheumatism, and are generally followed by the
subsidence of the disease of the joint. The patients are exhausted
or cachectic, and the head symptoms are more or less indicative of
inflammatory irritation of the brain or its membranes. In my own
experience the form of delirium I have mostly met with in rheumatic
fever has been of the first kind, and has chiefly occurred in cachectic
or feeble subjects. In one instance which I shall presently relate
the head symptoms, which were of a highly sthenic character, coin-
cided with cessation of the articular afl"ection, which reappeared
again to some extent as the former gave way. There seems much,
reason to think that the exciting cause of acute rheumatism, whether
it be an imponderable influence, or a material virus, attaches itself
especially to the nervous system, and works through it. If the
nervous power is strong and steady, the inflammatory phenomena
will proceed in an orderly manner to the termination of the disease.
But if the reverse is the case, if the nerve power is weak originally,
or gets exhausted by injudicious treatment, the irritability of the
brain becomes greatly increased according to the general law {v. p.
44), and it is affected in a much more intense measure than it would
have been in a stronger state. This is an instance we think where
a judicious solidism is essential to true pathology, and to successful
treatment. The exciting cause of rheumatic fever must be no doubt
the same in all cases. Yet in the great majority the delicate struc-
ture of the brain is unafi"ected by the poison, or the morbid influence
whatever it be. In a few however who have less resisting power
the function of the nervous tissue is disordered. Clearly the prin-
cipal object of treatment should be (in such cases) to strengthen and
aid the weak organ to bear up against the perturbing agency. For
this opium and stimulants are requisite. Though theory might
incline us to try to quell the irritation by thorough alkalization of the

104 CEREBRAL EXCITEMENT.

system so as to neutralize the presumed acid materies morbi, yet
practically we find that this is insufficient, and that we must deal
with this and with all the visceral complications of rheumatism as sub-
stantive disorders. The same indeed holds true of delirium in all
cases ; it must be treated according to its quality, without regard to
its presumed cause. In such asthenic delirium as we have been con-
sidering the disorder of nutrition may be well compared to that exist-
ing in neuralgia, a non-inflammatory molecular derangement of the
tissue. In sthenic delirium it approaches more to inflammatory
action, and probably in extreme cases may pass into meningitis.

As regards the treatment of active delirium very much of course
depends on the nature of the affection, and the presumed pathologi-
cal state. If the disorder be of sthenic character, various depressamt
measures will be found essential. It is the fashion with some to
depreciate Abercrombie, but there seems to be no question (unless
we accuse him of deliberate falsehood) that he has left us most valu-
able records of the successful treatment of cerebral disease as- it
occurred in his day. I do not see if we accept his cases as truthful
records that we can question the beneficial eS"ect of general and local
bleeding, and of hard purging. Abercrombie candidly states that
the cases terminating favourably form but a small proportion to the
whole of those he has met with, but this does not alter the fact that
in certain cases this evacuant treatment was successful. I am not
at all disposed to be a blind worshipper of authority ; I desiderate
carefully-recorded observations in proof of general views, but when
I have these I shall not reject or ignore them because they do not
accord with my own experience. Abercrombie's testimony is fully
corroborated by that of other observers, and looking at the whole
no doubt exists for a moment in my own mind as to the propriety
of adopting the means he recommended when we have sthenic con-
ditions of system to deal with. Dr. Marshall Hall places congestion
of the brain at the head of the list of disorders which increase toler-
ance of bloodletting. It is scarcely necessary to say that if vene-
section be requisite it should be performed in such a manner as to
make a speedy impression on the system, and induce semi-syncope.
The importance of choosing the right time for venesection has often
been pointed out. As a remedy it belongs to the initiatory period
of inflammation, before exudation to any amount has taken place,
while the heart's action is forcible, and the bloodvessels retain their
tone. In tropical fevers it is of vital consequence to employ it sea-
sonably. Ranald Martin writes, " What was a saving means at the
commencement of the paroxysm is as surely destructive at the end
of it." In minor degrees of sthenic delirium leeching the head may
be sufficient; Graves and Corrigan speak very favourably of its effects.
The application of cold to the head is also a means of prime impor-
tance. Southwood Smith adduces cases to show that where head-
ache and delirium are present, and the lancet is inadmissible, placing
the patient in a warm bath, and directing a forcible stream of very

CEREBRAL EXCITEMENT. 105

cold water on his head, soon renders hun more calm, relieves his
headache, and for the time dissipates the cerebral symptoms. Graves
adds his testimony that the effects of this remedy are extremely re-
markable, and thinks that many of the cases in which he has employed
tartar emetic with such signal advantage would derive equal benefit
from this mode of treatment. Von der Decken and Brand' have
lately found baths and cold affusions of eminent service in typhus,
especially in tranquillizing the brain and preventing delirium. Aber-
crombie prefers the cold stream to the application of pounded ice,
but warns us that it is a remedy of such power that it requires to be
used with discretion lest it produce excessive prostration. It is
most probable that the modus operandi of the cold douche to the head
consists in its exciting in the cutaneous nerves an impression which
is propagated through the centre to the vaso-motor nerves of the
cerebral arteries, and induces their contraction. On the same prin-
ciple, viz., of inducing anaemia, a stream of watei has long been used
in some countries as a means of sending children to sleep. ^ Tartar
emetic combined with opium has already been mentioned as a power-
ful remedy in violent cerebral excitement. Graves by no means
proposed it as a specific to be given in all conditions ; he does not
advocate its use at the commencement of fever, when other anti-
phlogistic measures may be more advisable, but at a later period,
when symptoms of general debility announcing the typhoid type
begin to predominate ; and when the condition of the patient approxi-
mates to that observed in certain varieties of delirium tremens.
Graves lays down that the relative portions of tartar emetic and
laudanum must be varied according to circumstances. "When con-
gestion of the brain is known to exist or is feared, the tartar emetic
must not fall short of 4 grains in the 8 ounces, while the laudanum
should not exceed half a drachm; but when nervous symptoms pre-
dominate the laudanum may amount to '^i, and the tartar emetic to
gr. ij ; no general rule, however, can be laid down, and the practi-
tioner must in all cases watch the effect of this medicine from hour
to hour, until he ascertains whether it agrees with the patient or
not." It is clear from Graves's cases that he considers the exist-
ence of very marked debility no contra-indication to the treatment.
He states that it has sometimes disappointed him, but makes no
mention of any disastrous effects produced by it. We have heard
from those who have employed this remedy that such are by no
means impossible. It was not for mere nervous disorder that Graves
used tartar emetic and o;^ium, but for nervous disorder combined
with cerebral congestion. Wine, musk, porter and opiates would
control the nervous symptoms alone, but not when they were blended
with the effects of cerebral hypergemia. In some of the cases, but
by no means in all, the pulse before the tartar emetic was given was

1 Schmidt's "Jahrb.," vol. cxvii. p. 125.

2 Graves's "Cliu. Med.," p. 745. ■,

106 CEREBKAL EXCITEMENT.

small and wiry as well as frequent. The action of tlie medication
was always to reduce the frequency of the pulse and render it fuller,
and in some cases much softer. It is unfortunate that we have no
information as to the quality of the first sound of the heart in the
cases which Graves relates. One cannot but entertain much appre-
hension that tartar emetic would be a perilous drug to exhibit when
the heart's tissue was seriously softened and enfeebled. Ackermann^
always observed after injection of tartarized antimony a diminution
of the force of the blood in the aorta, which took place whether the
frequency of the pulse increased or diminished, but was greatest
with a slow pulse. In dogs killed by tartar emetic the irritability
of the heart examined immediately after death was remarkably di-
minished, and sometimes altogether extinguished. On the whole
the safest conclusion that one can arrive at with regard to this medi-
cation seems to be that it is chiefly appropriate to conditions charac-
terized by high nervous excitement associated with more or less
active cerebral hypersemia. One of the best criteria for judging of
the degree of cerebral activity will be the capacity displayed for
muscular exertion. If this be considerable, it is clear that a good
deal of vis nervosa must still exist, and we may proceed more boldly.
Some important general inferences may be drawn from the remark-
able facts ascertained by Graves. (1) That in certain morbidly
excited conditions of vital power depressing remedies are well borne
and may be essential to preserve life. (2) That this morbid excita-
tion may be confined to one organ, as the brain. (3) That tartar
emetic operates as a tissue sedative, and when it acts most favoura-
bly confines its sedative action to the morbidly excited organ. The
case first alluded to illustrates forcibly the two last propositions; the
brain was violently excited but the heart was far from being so or
any of the other organs; — the antimony produced no depressing
effect but seemed to expend itself on the brain. This is what it has
been found to do, when it has acted most beneficially in pneumonia,
but this is just what it is often at the present day impossible to
insure.

Colchicum is a remedy which has been found of admirable effect
in calming high delirium of sthenic character associated with cere-
bral hypersemia. Dr. Hamilton Roe gives gr. v of the powder
every two or three hours until the face is blanched, and the morbid
action quieted. In some visible inflammatory affections of the eye
it acts similarly. It is a remedy of the same kind as tartar emetic,
and to be used with the same precautions.

Hydrocyanic acid has lately been strongly recommended by Dr.
M'Leod^ as a powerful calmative in acute maniacal conditions where
no grave structural change exists, and where the morbid action has
not become as it were stereotyped by frequent recurrence. He con-

> Virchow's " ArcMv"— "Brit. Med. J." Aug. 29, 1863.
2 "Med. T. and Gaz,," March 14, 21, 1863.

CEREBRAL EXCITEMENT. 107

siders that it checks the morbid activity of the brain, '' the excessive
and purposeless cerebral vigour." Sound sleep sometimes follows,
but is by no means a necessary result of its beneficial action. The
dose is ^y every quarter of an hour till some manifest effect is
produced. If there is any difiiculty in administering it by the mouth,
the method of subcutaneous injection may be employed. In the
latter case the ^iv of acid are to be combined with "\,xxx of water.
M'Leod has no doubt from his experience that it has the power of
promptly staying cases running on to chronic insanity on the one
hand, or exhaustion and death on the other. As its best ascertained
therapeutic effects consist in removing various neuralgic affections,
it is probable that it is more appropriate to states of the brain in
which simple excitement of the tissue constitutes the disorder, than
to those of which hyperasmia forms an essential element. It is a
less depressing remedy than the two preceding, but an over-dose
produces a stuporous condition and other phenomena resembling,
those attending an epilepsy.

The foregoing remarks relate to the treatment of sthenic delirium,
but we have seen that acute or active delirium may be asthenic. It
may be no easy matter to distinguish between cases requiring de-
pressant measures, and those for which stimulating are essential.
If we read Grave's remarks on the subject of giving wine and opium
in fever we cannot but remark that he felt it not uncommonly to be
a difficult question to decide when they were to be given, and when
withheld. He states, " that we must rely in the more advanced
stages of fever on the tact acquired by previous experience and re-
flection, and must often depend more upon a correct estimate of the
general state of the patient than upon the appearance or absence of
any particular symptom.'" Sleeplessness with restlessness and irri-
tability, the patient constantly endeavouring to leave his bed and
having delusions — these symptoms may urgently demand wine and
opium. Violent and continuous delirium forbids, in Graves's opinion,
a stimulating treatment, but this does not hold if though there be a
good deal of raving it is nocturnal. Stokes gives a case (p. 404)^
where there was violent delirium throughout the night (two days
later it is simply reported that there was such delirium without
specifying that is was nocturnal), in which 16 ounces of wine daily
with camphor, musk, and opium appeared to be highly beneficial.
In one of Dr. Todd's cases of erysipelas^ the patient had such violent
delirium and created so much disturbance that he was obliged to be
placed in a separate ward. With |ss of brandy every two hours
and ^,xx of laudanum every four hours the delirium was unabated,
but diminished considerably and soon ceased after the brandy had
been given every hour, and the laudanum had been replaced by
bark, chloric ether and ammonia. In another case, one of epileptic

1 " Clinical Med.," p. 187. 2 "Dis. of the Heart and Aorta."

8 "Clin. Lect. on Acute Diseases."

108 CEREBRAL EXCITEMENT.

delirium, very violent and constant delirium subsided in about four
days under gss of brandy every hour, with carbonate of ammonia
and laudanum every four hours. The pulse steadily declined in fre-
quency during the administration of the stimuli. Todd speaks very
confidently also of the efficacy of alcohol in preventing delirium in
patients suffering under various acute diseases. He evidently holds
that it is better to err on the side of giving too much than too little
stimulus. The points to \¥hich we should have most regard in en-
deavouring to determine the quality of the delirium we have to deal
with are : (1) The general condition and constitution of the patient ;
(2) The state of the urinary secretion; (3) The state of the pulse;
(4) The quality of the first sound and impulse of the heart ; (5) The
state of the pupil ; (6) The state of the skin ; (7) That of the bowels.
If the patient be enfeebled from any cause, and has not previous to
his illness enjoyed vigorous health ; if his urine is in good quantity,
not highly acid, red, or of high spec. grav. ; if the pulse is easily
compressed ; if the first sound of the heart and its impulse are weak ;
if the pupil is dilated ; the skin not very hot and dry, and the bowels
relaxed, we have good grounds for expecting that stimulants will be
beneficial. In proportion as the above signs are less marked, the
indications become less clear, and we must resort to what is often
a wise proceeding, viz., testing the condition of the system with some
remedies, the result of which may lead us to take the right course.
The more we can perceive the signs of excitement without power in
the cerebral disturbance, the more bold we may be in our adminis-
tration of stimulants and support. In cases of this kind opium is
often necessary, and its dose must depend on the degree of excite-
ment, and on various other circumstances. Too small doses may
only aggravate the excitement, and too large may bring on dangerous
or fatal stupor. The determination of this point is one of the most
delicate in therapeutics, and cannot be solved, at least in all instan-
ces, by administering small tentative doses in succession. I am
much inclined myself to give large doses of hyoscyamus, as 9j of
the extract, in cases where it might not be safe to give a full dose
of opium. If we prefer the latter the amount of cerebral excitement
is the chief measure we have of the quantity of the drug which will
be requisite to calm it. If the pupil be contracted, belladonna may
be given as an hypnotic with advantage as Dr. Murchison tells us.
Hyoscyamus would probably be suitable in the same state. In
cases of the kind we are now considering brandy mixed with milk
will be found one of the best forms for administering stimulus and
food. It should be given of course at very short intervals, say 5ij
of brandy -f oSS or 5vj of milk every hour or half-hour.

No. 27. — W. L., set. 25, of spare frame, delicate constitution, carpenter,
seen March 28fch. Ill with acute rheumatism about ten or twelve days, his
head began to be affected two days ago. Five years ago he was under Mr.
Culpepper's care for a very severe attack of acute rheumatism; attended

CEREBRAL EXCITEMENT. 109

with endocarditis and pericarditis. Five years before that he was under my
care with similar disease. On March 21st he had ten leeches to the precordia
for threatening cardiac inflammation, poultices were subsequently applied,
and calomel and Dover's powder given every three hours with a draught of
pot. nitras, potas. bicarb, and sod. phosp. 25th. Is nearly free from the
pains and swelling of the limbs except in the extensors of both feet; skin
still exudes an oifensive copious perspiration. 26th. Gums affected. Rheu-
matism has quite disappeared, just as it did five years ago suddenly while
the pericardium became inflamed. Calomel omitted, Dover's powders and
salines continued. 27th. In the course of the night he became quite de-
lirious and incoherent, uttering alarming shrieks so as to disturb the neigh-
bours, with fits of fearfulness and apprehension that the ceiling was about to
fall, &c. Eyes wild and restless, can scarcely be made to comprehend any
question. Head hot and skin generally. Tongue dry and covered with
yellow crust. No urine passed since last evening. Hands are tremulous as
in delirium tremens. Hair cut short and cold applied to head, hot mustard
fomentations to the feet. Opii gr. i 3tiis horis with effervescing draughts.
Furious delirium continued all the day; four persons were required to keep
him in bed, he would not take the pills or mixture. At 5 P. M. Mr. Cul-
pepper gave him gr. j of opium, and at 9 P. M. gr. ij, matters were then
greatly worse. At 11 P. M. Mr. C. was sent for, the patient was said to
be in a strong fit of convulsions. When he saw him, he was in a terribly
excited state, eyes staring, jaws clenched^ heart beating violently. Pulse
130. Great heat of surface. Tr. digitalis 5ij + tr. opii 5j W'lS directed
to be given in two doses, at 12 and 3 A.M. At 6 A. M. he had liq. opii
sed. 5j in two doses. I saw him with Mr. Culpepper at 9.30 A. M., and
learned the above history and that he had had no sleep for two nights.
Pulse 117, of good force. Tongue denuded, cracked, red, covered with
sordes. Is partially conscious, does what he is told, says he has no pain
anywhere, is constantly talking deliriously. Rheumatism has quite disap-
peared in spite of counter-irritation to the limbs. Urine passed in bed.
Head rather hot. Heart's sounds fairly clear, no pericardial effusion, slight
questionable exocardial bruit. Right pupil dilated until lately, is now of
medium size and fixed. Left eye lost. No pneumonia or bronchitis. We
agreed that he should have six leeches to the temples, cold to his head, and
gp. I of tartar emetic every half hour.

31st. He began the treatment at 11 A. M. of 28th, and took gr. ^ every
half-hour till 11 P. M., when the pulse was 95, the skin was cool, and the
delirium nearly abated, in short everything going on well, which induced
Mr. C. to give the mixture less frequently, every one or two hours. At 5
A. M. of 29th he was not so well, so the mixture was given as before with
liq. opii sed. n^iv in each dose, and from that time to 10 P. M. of 30th he
has made rapid and permanent improvement, and is now quite himself again
in every respect, asking for and taking food, and knowing every body about
him ; delirium quite ceased. In fact but for the return of the pain and
swelling of the right hand one could not say what had been the matter.
The left shoulder is also painful. Complexion clear, countenance calm,
pulse 86, and respiration tranquil.

April 1st. Sleeps and eats well; omit the antimony and opium. 2d. A
light tonic with sodse phosph. was given, as the urine still deposited lithates.
Joints free from rheumatism. 6th. Is up and dressed and considers him-
self quite well. Mr. Culpepper, to whose kindness I am indebted for the
report of the case, adds that during the four days he took over 30 grains of

110 CEREBRAL EXCITEMENT.

tartar emetic and 5ij of" lio(- opii sedat. Rheumatic pains reappeared on
night of 29th and continued till April 3d ; all other symptoms gradually but
most distinctly abated, and not the slightest bad effect was produced by the
antimony, no approach even to nausea or sickness, or purging, or depression
of the heart's action. After the 30th the medicine was given less fre-
quently.

Remarks. — There can be no question that the tartar emetic was really
the eflScient means of this patient's recovery. Opium had been taken pre-
viously without benefit, and was not given the first day, when nevertheless
a considerable sedative efi"ect was produced. The relapse which ensued when
the antimonial was given less frequently, and the steady improvement after
it was resumed at the former rate, prove that it was the chief remedial agent.
Its action seems to have been remarkably limited to the brain calming the
excitement of its tissue without producing any other notable effect. The
case was evidently not one of ordinary rheumatic fever delirium; there seems
to have been actual metastasis of the morbid action from the joints to the
brain, with subsequent recurrence of it in its usual site. Considering that
the heart had been severely attacked before I think it - is very doubtful
whether there was any actual affection of it on this occasion. If there was
it was slight, and had I believe no connection whatever with the cerebral
symptoms. Altogether the case may stand for a Uapabeiyixa of sthenic
delirium.

The following case related by Dr. Posner^ is worth comparing
with the foregoing : —

No. 28. — A man, set. 37, fell ill of acute rheumatism. Both hands were
affected, the pulse was 100, and the other symptoms were as usual except
that he was remarkably restless. The inflamed parts were much relieved
by leeching, but the elbow-joints became engaged, and the upper arm and
neck muscles were painful. On the next day after considerable delirium
the joints became quite painless, the pulse was 65, the patient only com-
plained of occipital pain. There was no indication of intercurrent delirium
tremens, the cerebral disorder was viewed as a rheumatic meningitis, and
treated by local detraction of blood, and ice applications, with tartar emetic
opium internally, and mustard poultices to the joints which had been in-
flamed. The delirium continued two days and nights in spite of repeated
bloodletting, the pulse fell more and more, and the joints remained painless
until large doses of opium were administered, which produced on the third
night sleep for seventeen hours, out of which the patient awoke rational but
with severe pains in the neck and stiffness of the elbow-joints. The pulse
had risen moderately and the general condition was better. After a second
tranquil night the pain returned in the joints which had become affected
with all its former severity, and this condition lasted some days, when it
suddenly ceased, and in its place the old cerebral symptoms returned. These
yielded again to the opiate treatment, and the joints became affected for the
third time, and remained so until the disorder disappeared entirely in about
fourteen days. The heart was never attacked.

No. 29. — Mr. L., set. 25, a delicate man, seen in consultation with Mr.
Gr. Brown, Dec. 13th. He had been ill about ten days suffering with

1 " Med. Ceatr. Ztg.," sxviii., 27; 1859.

CEREBRAL EXCITEMENT. Ill

rheumatic pain and latterly with some pleuro-pneumonia of both lungs at
the posterior bases, most marked and extensive on the right. Respiration
very quick and shallow, 60 in the minute. Pulse 108, weak. Skin cool.
No cough, or expectoration. Extreme thirst. Tongue thickly coated.
Heart's sounds normal. Ordered mist. pot. citrat. efferv. 5j, tr. opii
ITLTJ, pot. iod. gr. jss, spt. a3th. chlor. iil,xij, 4tis horis. Opii gr. j statim.
Dec. 14th. Slept well, respiration 30; feels better. In the course of the
following night Mr. Gr. B. was sent for, as the patient had become " raving
mad." He gave him gr. j of acet. morph. + gr. v of calomel, and repeat-
ed the same in two hours. This speedily quieted him, so that the following
day he was quite rational. He was now well supported with a very generous
diet, and made a good recovery.

No. 30. — W., f., set. 30 (about), seen Sept. 10th. Has had swelling and
purpuric eruption on right leg last four days, and the last two on right elbow.
Leg much swelled and very tender. Is markedly weak, has not been with-
out vegetables. In two days with iron and quinine and citric acid the pur-
pura had disappeared, and two days later rheumatism commenced. Nitre
and citrate of potash saline. 18th. Was delirious all last night, is rational
this morning, but intellect not quite clear. Heart's sounds normal ; ordered
mist, ammon. acet. oj + ammon. carb. gr. iij, Atis horis. Brandy ^ss
Idis horis. Broth diet. Beef tea. After this there was no more delirium,
but the rheumatism though never more than subacute lingered about her
for a long time. She did not leave the hospital till the end of October.

No. 31. — Mrs. B., a young-looking primipara, confined six days ago,
seen Jan. 27th with Mr. Ferguson. She had a quick and on the whole
favourable labour : the pains being sharp and strong. The milk and lochia
have continued : she has had no unfavourable uterine or other symptoms,
no indication of fever. She has been quite sleepless and maniacal, raving
and talking continually ever since her confinement in spite of large doses of
opium, as much as 5ss of liq. opii sed. in one day, and some large doses of
henbane. They have quieted her a little, but not much. She answers
quite rationally when spoken to by me, but as soon as she is left talks deliri-
ously. Urine normal. Bowels have been confined, are open now, and she
has been better since. Pulse of tolerable strength, 88. Circulation active
in forehead, the skin reddish and is scarcely pale for a moment after the
pressure is removed. We agreed to give ant. pot. tart. gr. \ + liq. opii
sedat. TTLx 2dis horis. This medication made her much more delirious; it
was difficult to keep her in bed. Mr. F. then administered tr. hyoscy. 5ijj
^tiis horis, with which she became quieter ; had a good night Feb. 2d, and
improved materially. The antimony caused vomiting after four doses and
flushing of the face. She went on taking tr. hyoscy. About 5^ daily for
some days and quite recovered.

Remarks. — In this last case the treatment which succeeded so well in
the first was evidently inappropriate. Yet from the appearance and con-
dition of the patient I had great hopes that it would prove successful. Per-
haps it may not have been altogether useless, by rendering the brain more
amenable to the influence of the henbane than it had been previously. In
this respect the utility of what are called lowering remedies is I think some-
times overlooked. They may not apparently eS"ect much themselves, but
they prepare the way. for others. The conclusions to be drawn from the
above cases seem to be these. (1) That the quality of the vis nervosa in
delirious disorder varies greatly, (2) That it may be very difficult to ap-

112 CEREBRAL EXCITEMENT.

predate or gauge this quality correctly. (3) That nevertheless it is most
important to do so, as the treatment depends upon it. (4) That any exclu-
sive mode of treatment by stimulation, or the reverse, or by sedatives is
out of the question.

CHAPTER X.

DELIRIUM TREMENS.

We next come to the state known as delirium tremens. This is
for the most part considered to be invariably the result of alcoholic
excess, but I think there can be little doubt that a state closely
resembling it, if not identical, may be generated by other causes.
Watson states that this may happen from prolonged anxiety, J.
Johnson from over-study. In continued fever a state closely resem-
bling delirium tremens is not unfrequent. The case is narrated^ of
a stoker of good character serving on board H. M. S. Reynard, who
fell apparently in consequence of excitement at the murder of two
of his shipmates by the Japanese into a state of perfect delirium
tremens, not one symptom being absent. It was proved that he
had not been indulging in alcoholic excess. He was put to sleep
with tr. opii ^ 40 + chlorof. ^ xv. Fox records^ a case to the same
eifect, the disorder supervening on exposure to cold and wet. He
is positive that no indulgence in intoxicating liquors had anything
to do with its production. Dr. Monckton^ relates the case of a
female, set. 28, who rather more than three months after her con-
finement presented an almost typical state of traumatic delirium
tremens; "the breast abscess consummating the overthrow of brain
equilibrium," for which previous and successive mental shocks had
prepared the way. This testimony as to the production of delirium
tremens by other causes than alcoholic seems to me very important,
as proving that the peculiar morbid state is not necessarily one of
poisoning at all. It may be a sequela, or result of poisoning matter,
■which has passed away from the system, or may be solely a diathesis.
The discussion which has lately arisen respecting the proper treat-
ment of delirium tremens makes a careful reconsideration of its
pathology necessary. Those who contend that the disease is specific
and dependent upon alcoholic poisoning deny that it ever originates
from deprivation of the customary stimulus, and assert that in all
instances where this is apparently the case the paroxysm has only
been accelerated in its arrival by the accident or disorder, which
has interfered with the usual indulgence. Dr. Marston however

I "Lancet," Oct. 11th, 1882. 2 « Laucet," May 7th, 1859.

s "Edin. Med. J.," Oct. 1860.

DELIRIUM TREMENS. 113

adduces evidence^ which very materially corroborates the older
view, and taken together with other experience renders the above-
mentioned hypothesis very questionable. He shows that delirium
tremens does come on in soldiers commonly from the first to the
seventh day after the privation of liquor, and this in men who had
not suffered from it before. He argues, I think, convincingly and
conformably to the analogy of other similar agents, that the nervous'
system becomes habituated to the constant use of alcoholic stimulus,
so that, although more or less injured by it, it feels seriously the
deprivation. Probably most of us have some familiar experience of
a similar kind. Thus men who have been accustomed to take wine
or beer moderately have tried to leave them off for some reason or
other, but found their efficiency for work so much impaired thereby,
that they were obliged to resume their usual allowance. This is
on a minor scale much the same thing as occurs in some cases of
delirium tremens. On the other hand, it seems to me that if this
disease was invariably the direct result of alcoholic poisoning, the
good effects of abstinence ought to show themselves very speedily
and decidedly, so as to put the matter out of all question.

Dr. Laycock, who has taken a principal part in advocating the
abandonment of the former routine treatment by opium, considers
delirium tremens as "a vague term." He thinks that various cere-
bral affections of melancholic character are grouped under this head,
that our diagnosis is imperfect, the etiology obscure, and the patho-
logical anatomy altogether erroneous. He does not appear to dis-
tinguish, certainly not pointedly, the acute disease termed by some
D. ebrietatis from the more chronic affection attended with depres-
sion. Yet this seems to be a main point. Dr. Blake regarded them
as opposite and distinct diseases, the one being the immediate conse-
quence of intemperance, the other arising from the sudden cessation
of accustomed intemperate stimulation ; the one requiring the cau-
tious use of depletion, the other the administration of stimuli ; the
one belonging to the phlegmasiis, the other to the neuroses. Cop-
land makes a similar division of the disease into species; "the one
being evidently connected with inflammatory irritation of the arach-
noid and associated with great irritability ; the other consisting chiefly
of this last state attended by exhausted nervous energy." He adds,
however, immediately, and this seems very important, "yet it often
presents intermediate forms or modifications, which cannot be referred
to the one species more than the other." He insists that the treat-
ment should be modified according as it approaches to the one type
or to the other. Dr. Marston in his excellent paper (loc. cit.) makes
the same distinction, and further groups in a separate class cases
which are complicated with visceral disease, renal, hepatic, gastro-
enteric, central. The first form, he says, evidently implies acute
alcoholic poisoning, while the second is a delirium of drunkards in

' "Brit. Med. J.," Dec. 19th, 1863,

114 DELIRIUM TREMENS.

contradistinction to a delirium from drink. The subjects of the
first class are soon right after an emetic purge, and two or three
days' quiet. Those of the second after free purgation will probably
require opium and stimulants. Graves, though not separating his
cases so widely from the etiological point of view, lays down most
positively the necessity for very different treatment in diflFerent
cases. In the young and robust, the disease may demand strictly
antiphlogistic measures, including venesection, leeching, and cold
to the head ; while in the old debilitated and confirmed drunkard,
"we are often obliged to exhibit opium from the very commence-
ment, and that in large doses combined with stimulants." Between
these extremes, he proceeds, there are many intermediate varieties,
each requiring a special modification of practice. Tartar emetic
boldly exhibited is often our sheet-anchor in delirium tremens, espe-
cially when there is evidently active determination to the head. In
some cases it may be given alone, in others combined with opium.
Mr. Solly, we suppose, states only the general experience of surgeons
as to the liability of habitually excessive drinkers to suffer from
delirium tremens, when after the shock of an injury they are re-
strained from their usual indulgence. Mr. Erichsen' only differs in
recognizing two distinct types of traumatic delirium, " the one inflam-
matory, the other irritative," the treatment of the first being strictly
antiphlogistic, that of the other requiring full doses of opium, con-
tinued until either sleep is induced, or the pupil contracted : — while
if there be also much depression, stimulants are requisite. . He dis-
tinctly admits that this disorder may befall persons who are not
intemperate, but who have an irritable nervous system. Dr. Peddie^
considers that the state of the brain in delirium tremens is one of
alcoholic erethism, the alcohol occasioning those relative changes in
the sanguiferous system of the encephalon, the tendency of which
is to pass from irritation, from abnormal activity of circulation and
function, to inflammatory action, according to the severity of the
attack, and other circumstances. He treated eighty cases with uni-
form success by tartar emetic in doses of gr. i-| in simple solution
every two hours, or at shorter intervals, according to the degree of
excitement and irritability. The action of the antimony appears to
be chiefly sedative. Its direct influence is to reduce the vascular
excitement of the brain, soothe the nervous system, and diminish
muscular power, and its more indirect action is exerted on the func-
tions of the skin, kidneys, and intestinal canal. The advocates of
the more recent view hold that delirium tremens is a specific toxae-
mia from alcoholic excess, and does not consist merely in the
nervous irritation and exhaustion consequent on the withdrawal of
a favourite stimulus. They insist that many persons cease from
alcoholic excess, and become sober without suffering in any degree
from this disorder. The records of prisons are appealed to to es-

" Science and Art of Surgery," p. 90. 2 ugjin, iyiecl. J.," June, 1854.

DELIRIUM TREMENS. 115

tablish this point. The occurrence of traumatic delirium in drinkers
is explained by supposing the injury to induce the earlier occurrence
of a paroxysm which would have ensued without it, just as an attack
of influenza or some other casual disorder might have done. If a
mere expectant treatment be followed, according to Dr. Ware, of
Boston, a paroxysm of delirium tremens terminates by natural sleep
in from sixty to seventy-two hours, dating from the time when the
state of entire watchfulness and delirium commences. The mortality
on this plan is stated to be extremely small, only one death having
occurred in twenty-nine, and this case being complicated with acute
disease ; while out of fifteen cases treated with opium in small or
large doses six died, two of these being complicated. On the other
hand in the Edinburgh Infirmary, where for many years the dis-
ease seems to have been treated with laudanum and whiskey in a
very careless manner, the mortality is stated to have been 35 per
cent.; and in St. George's Hospital 14.6 per cent.; in the infantry
regiments 17.6 per cent. ; and in the cavalry 13. 8 per cent. Dr.
Gairdner's recent experience at Edinburgh is of one death among
thirty cases treated in an extremely simple and natural manner,
and that one being complicated with a very extensive double pneu-
monia. Laycock himself has treated sixty-eight cases without opium
or stimulants, and has had only two deaths. These statements
certainly deserve grave consideration. The one which is of main
importance is the assertion that the paroxysm of delirium tremens
is self-limiting, ceasing as Dr. Ware affirms in from sixty to seventy-
two hours. Dr. Laycock indeed extends this period considerably,
to from four to fourteen days (his cases averaged six). This is cer-
tainly a considerable discrepancy, the shortest period assigned by
Dr. Laycock being a day longer than the longest given by Dr. Ware.
It would indeed require a considerable faith in the spontaneous ten-
dency of the disease to a favourable termination to allow a man to
remain sleepless and raving day after day without making judicious
efforts to procure sleep. Dr. Laycock indeed seems to think that
sleeplessness is no such serious matter ; he says that he knew one
gentleman who never slept a moment for a month yet with no bad
results. Drs. Watson, Latham, and Grattan think very differently
as regards the state of fever patients, which the former expressly
compares with that of delirium tremens. They state that two or
three nights spent in restless delirium are followed by the worst
consequences, and that patients who pass three nights in succession
in that way almost invariably die. Now though we admit that the
delirium tremens patient may, at least in some cases, have more
vital resistance than the fever-stricken one, yet it can by no means
be granted that continuous sleepless delirium will not tend very
materially to induce exhaustion, and death by asthenia. That a
routine treatment by laudanum and whiskey is not advisable is most
freely conceded ; we no more wonder at the high mortality under
such a regime, than we do at that which results in pneumonia, when

116 DELIRIUM TREMENS.

a numb.er of patients are taken indiscriminately, and all are treated
by bleeding. Our belief is that our practice in delirium tremens,
as in all other diseases, should be to a very great extent governed
by the vital condition of the patient. If we had a case of continued
fever where the symptoms were mild, and there was no remarkable
excitement or depression, we should not interfere and require the
patient to swallow a dose of wine or brandy every hour as we should
do if there were indications of perilous depression. We hope we
have learnt the truth of Schonlein's wise saying that it often happens
to good physicians to find no indication for treatment, to bad ones
never. On this view we quite understand that there may be many
cases of delirium tremens in which a purely expectant treatment
would be the best proceeding. This will specially be the case when
the disorder supervenes upon a recent debauch ; and when all that
is needed is to enable the patient quietly and safely to recover from
its injurious effects. Dr. Laycock seems to have met with this state
so often, twenty-one out of twenty-two patients alluded to by him
in his first paper' being actually alcoholized when they were admit-
ted into the hospital, that we cannot but think that his cases are
mostly of the acute toxsemic character. The only one which he de-
tails in his second^ paper was a case of prolonged debauch, in which,
though sleep did come on in nine days without sedatives, we are by
no means convinced that it might not have been advantageously
induced much sooner. The points which seem to us fully established
by the widest experience are the following. (I) That cases of de-
lirium tremens differ often very widely from each other, and that
their management must vary accordingly. (II) That this difference
may depend, (a) on the original strength of the constitution ; {b) on
the degree in which the nervous and other systems have become
impaired by habitual excess, by anxiety, or other causes ; (c) on the
tendency to sthenic inflammatory excitement of the brain ; {d) on
the circumstance whether the disease succeed immediately to a
drinking-bout, or supervene on a condition of chronic regular tippling,
which has been accidentally interrupted.

Before proceeding to illustrate the above points we would remark
that it does not seem wise to set aside and ignore the experience of
our predecessors because it does not agree with our own. We hold
that all facts, faithfully observed and recorded, have an undying
value, they may not accord with others which occur at different
times and places, nay, they may seem to be contradictory, but if
they be real facts, they must be taken into account in any attempt
to construct a true theory of the disease. It is marvellous how
prone the best of us are to one-sided views, how averse to look
fairly at all sides of a question. We remark further that with
regard to what Dr. Laycock calls the heroic treatment of delirium
tremens, it is impossible to suppose that it is entirely negative.

» "Edin. Med. J.," Oct. 1858. 2 Ibid., Mar. 1862.

DELIRIUM TREMENS. 117

Either it must do good, or be injurious in the great majority of
cases. He himself is not sparing in his anticipations of evil, con-
cluding that " the continued or increased use of the causes will
aggravate the effects, and change that which would otherwise be
acute and transient into a chronic and permanent, if not a fatal dis-
ease." It is also we think to be considered that we need in the
practice of medicine not only to have general rules for the manage-
ment of ordinary cases, but special directions for various exigencies.
Dr. Laycock is scarcely consistent with himself in allowing the use
of alcoholic stimulants (4 to 6 oz. of brandy daily in one case) where
there is prostration, and in admitting that in one class of cases
opium and its salts have the "most beneficial effect." This seems
to me to concede nearly all that a judicious practitioner, who was
not prepared to adopt expectancy, would contend for.

Now, taking up our last point first, we think that all cases where
the symptoms ensue immediately on casual alcoholic excess, should
be distinctly separated from others where this is not the case. In
this we agree with Dr. Blake, Mr. Solly, Dr. Copland, Dr. Marston,
and Dr. Morehead. These cases may require very little treatment,
perhaps only an emetic and a purgative. Dr. Morehead' gives calo-
mel gr. viij -t- gr. j of morphia at bed-time after a hot foot bath
and cold affusion to the head. In robust young men he finds cupping
to the neck often useful. The nervous system in such cases being
in a tolerably sound state rights itself before long as soon as the
morbid influence has passed off. In other cases the attack super-
venes on a debauch, but the patient is also more or less habituated
to alcoholic excess previously, perhaps for many years. Here it
depends very much on the condition to which the nervous system
has been reduced by the previous intemperance what effect the
debauch will have. If the nervous power be tolerably intact, the
case will be nearly of the same kind as that first considered ; if the
reverse is the case, it may be much more serious. Dr. Brinton
gives a good example^ of a man who had been long addicted to hard
drinking, and was admitted after ten days' nearly continuous debauch
in a state of incessant struggling delirium, which continued for more
than twenty hours. He was allowed 3 to 6 oz. of brandy daily, and
vin. ipec. ^xv + tr. opii ^Lvij -j- spt. asth. chlor. n\^x was admin-
istered every three or four hours. In twelve hours he slept, and
was calm and rational the next day. When admitted he was in the
third or fourth day of his third attack of delirium tremens. Now
it is evident that the nervous system of this man could not have
been very profoundly deranged in spite of all his excesses, if he
could recover so rapidly under such simple means. But now, had
this patient had a tendency to inflammatory excitement of the brain,
such as Dr. Morehead describes as common among Europeans in

• " Eesearches on Disease in India," vol. ii. p. 533.
2 "Lancet," June 16th, 1860.

118 DELIRIUM TREMENS.

India, one may feel very confident that he would not have escaped
so lightly. He would then have been in the condition which Mr.
Solly describes as essentially one of hypersemia, and as more relieved
by a general warm bath, and cold to the head, than by any form of
opium. A case recorded by Dr. Peddie' illustrates this state well.
A man, set. 41, on the sixth day of his third attack of delirium tre-
mens was highly excited and delirious, attempting to get out of a
window. He had had previously smaller and less frequent doses of
antimony, but was now ordered gr. ^ every hour with beef-tea liber-
ally. After each dose, he was observed to become calmer and more
rational, slept soundly in the afternoon, and next day was quite con-
valescent. This case would surely have been rendered much worse
by opium and stimulants. It is on account of the prevalence of
such conditions in India, that Dr. Morehead has recourse so fre-
quently to tartar emetic and opium, giving gr. | of the former -f-
TT\^xxx of tinct. opii 2dis horis, and employing, if need be, at the
same time stimulants and cold affusion. The importance of the
original strength of the patient's system is well illustrated by the
following case which occurred in the practice of Dr. Hamilton Roe.
A publican, habitually intemperate, a strong thick-set man, was
walking about his shop in a state of considerable excitement, inco-
herent and wild, flourishing a knife, and refusing to take any medi-
cine. He was coaxed to take a pot of porter in which were dissolved
6 grains of tartar emetic. The result of this " quietner" was that
in one hour he was subdued, so as to take willingly gr. iij of opium,
which put him to sleep, and he awoke after six hours, perfectly well.
" II va sans dire" that there are not many cases of delirium tremens
which it would be advisable to treat in the same heroic way. But
it is abundantly clear that the remedies were highly appropriate,
and answered their purpose admirably. We cannot think that an
expectant treatment involving prolonged delirium for many days,
(Dr. Laycock gives a limit of fourteen) would have been preferable
to the above sharp and short cure. Such a case, or that quoted
from Dr. Peddie, may stand as a type of truly sthenic delirium tre-
mens, in the management of which stimulants are of course unde-
sirable. Dr. Fraser^ records two cases of delirium tremens in both
of which the pulse was full and rather hard, and the symptoms had
supervened on a recent debauch, the patients being robust working
men. In the first, sleep came after ^xx of tr. physostigmatis had
been administered, in the second where there was also limited pneu-
monia after ii^xxvj. Both were quite convalescent in two days. Dr.
F. limits the use of the remedy to sthenic cases, and weak pulse he
regards as a contraindication. He believes the physostigma to act
by depressing the action of the heart, and so lessening the supply
of the blood to the brain, in consequence of which the disposition
to wakefulness is. conquered. The following history probably de-

i V. Loc. citat. 2 "Edin. Med, J.," Aug. 1863.

DELIRIUM TREMENS. 119

scribes a condition in which the nervous power was less resisting,
though its excitement was equal to that displayed in the first case.
A strong male, of mid-age, habitually intemperate, had drunk hard
up to the time of attack. He was seen by Dr. H. Roe about forty-
eight hours after delirium had commenced, and had been treated
previously with small doses of opium ineffectually. His pulse, when
seen, was full and quick, skin rather hot, head hot, eyes and face
red and flushed, delirium rather fierce. Three grains of opium were
given at first, but had only the effect of causing further excitement.
Two hours after, 6 grains were given, which quieted, but did not
sleep him ; and three hours later he took 6 more, slept almost imme-
diately, and woke after six or eight hours quite rational and re-
covered. No stimulants were given. It seems to me that it would
be quite unfair to object that in this case the opium was not the
cause of the sleep which would have come on spontaneously with-
out. Fifteen grains of opium in five hours is no placebo, and beyond
all question had not the nervous system been in such a state of ere-
thism as to tolerate, and in a measure resist it, the dose would have
proved fatal. The administration of opium in such full doses re-
quires a master's discrimination, and I am by no means inclined to
advocate a frequent resort to such practice. That, however, in
appropriate cases it produces excellent results, is, I think, undeniable.
In many instances I am inclined to think large and repeated doses
of extr. hyoscyam. afford a safer sedative. Trousseau's rule for the
administration of opium is a good one; he says if the disease is 20,
opium must be 21. The difiiculty is to measure the disease correctly ;
we have no meter wherewith to gauge vital power. In strong con-
trast to both the preceding cases we place the one recorded by Mr.
Jones, of Jersey.' A male, £et. 48, seen Sept. 9th. Has had pre-
viously fits of the horrors, and has been muddled for the last two
months. Has had no sleep now for four days and nights. Has
taken opium in moderate doses, but has become worse. Pulse almost
imperceptible, skin covered with cold clammy perspiration, face
deadly pale, lips blue, hands tremulously grasping the air, the eye
expressive of great fear, the mind gone, incoherent muttering. Tr.
digitalis 5ss was given, in a few minutes the pulse was felt more
easily. No sleep occurred in four hours, but he was rather more
sensible, less tremulous and warmer : — the same dose of digitalis
was repeated. Three hours later he had had no sleep, but in other
respects was improved. A further dose of 5ij was given, making
5x in seven hours. After this he had some sleep, and slept at in-
tervals during the nig;ht. The next mornino- he was sensible, his
fears had disappeared, the skin was warm, pulse full and regular at
90. Heart's sounds and impulse normal. Bowels open. Urine in
natural quantity. After this he took some broth, drank freely of
imperial and lemonade, but took no stimulus of any kind, nor any

> "Med. T. and Gaz.," Sept. 29th, 1860.

120 DELIRIUM TREMENS.

Other medicine. He slept some hours in the afternoon ; the next
night was a good one, and the next morning he was almost well,
and calling out for a mutton chop. It is sufficiently clear that this
case was not one for the tartar emetic treatment whether in large
or small doses. Opium in moderate doses had failed, and large
ones would beyond doubt have soon destroyed life. The especial
indication was for a cardiac tonic, to restore the flagging circulation,
and this was well fulfilled by the digitalis, which, as I have elsewhere
endeavoured to show, has eminently this property. Had one to
treat such a case without digitalis, camphor, ammonia, tr. cinchon.
and stimulants would be the best means. In the three cases now
recorded we have examples of the three principal characteristics
which the disorder may assume : (1) that of inflammatory excite-
ment ; (2) that of nervous erethism ; (3) that of asthenia. In the
first the overwrought cerebral energy must be calmed by tartar
emetic with or without opium in adequate doses, cold to the head,
leeches or cupping if necessary. The iced bath has recently been
recommended by two American practitioners^ as a potent sedative.
They warn however that it may produce depression verging on syn-
cope. It is a remedy of the same kind as the cold douche in mania,
and like it must be used cautiously. In the second the non-inflam-
matory nervous erethism must be quieted by some sedative. Full
doses of opium often aff'ect this well, but small or insufficient ones
are apt to aggravate the disorder. In some cases where opium has
failed chloroform given by the mouth has succeeded. It is ques-
tionable whether it should be employed by inhalation. Dr. Corri-
gan thinks it highly dangerous in this disease, having known it
prove fatal in two cases. It should certainly not be used'if there is
the least tendency to failure of the heart's action. Henbane may
be used I think with advantage in this form of disorder ; 9j should
be given at once, and subsequently gr. x 2dis Jioris, till the pupils
are dilated or sleep is produced. In the third form the great dan-
ger is from the tendency to death by asthenia, which requires some
form of stimulants. At the same time the brain may be so irri-
table that there is risk of its being injuriously affected by the
very means which are necessary to maintain the circulation. Digi-
talis itself is perhaps as little likely to do this as any tonic, but in
two cases mentioned by Dr. Mackenzie it had the eflFect of changing
a state of timidity into the fury of acute mania, and in one I observed
myself (large doses being given) it acted similarly. Where it acts
favourably it must tell more on the sympathetic ganglia and nervous
centres influencing the heart than on the hemispheres. I believe
it to be more appropriate than opium to conditions of marked
asthenia, as there is decidedly risk of the latter still further
depressing the heart's action, while digitalis has the reverse eflFect.
It is hardly necessary to say that digitalis would be altogether un-

' "Amer. Med. Times," March 8th, 1862.

DELIRIUM TREMENS. 121

suitable for a case of sthenic delirium tremens, with fierce delirium
and inflammatory excitement. Hanbury^ relates a case of delirium
tremens where digitalis given to the amount of 5vij in a few hours
succeeded completely after opium had failed. The indications of
asthenia were well marked. Before sleep ensued the patient became
rational and laughed at his illusions, and the nervous agitation which
had been excessive subsided completely. M'Rea^ states that he
has given the digitalis treatment an extensive trial, in eighty cases
of mania and delirium tremens. He reports favourably of it. Of
37 cases 3 died, 2 with arachnitis and effusion. Carey reports^
four successful cases by the same method ; in all opium had been given
without good effect.

From the above exposition it must appear how necessary it is to
exercise a sound discrimination in treating a case of delirium tre-
mens, and how injurious any mere routine proceeding is likely to be.
Probably few things are more difficult than to judge correctly of the
vital condition of that vast accumulation of delicate cell-growth which
forms the cortical substance of the hemispheres. No appreciable
sign that we know of indicates it certainly. The pulse is no sure
guide, a weak pulse by no means always indicates a state of cere-
brum that will tolerate stimulants and tonics ; and on the other hand
a pulse may have much apparent force when these are urgently
needed. A cool or moderately hot, and clammy state of skin, a
languid lustreless eye, pale and copious urine very deficient in phos-
phates, and a timid delirium are we think the signs most indicative
of a state of nervous system which will tolerate and be benefited by
a stimulant and tonic treatment.

Believing as we do that delirium tremens, except in cases of acute
occasional excess, is much more than mere alcoholic poisoning, we
cannot doubt the propriety of administering judiciously the ordinary
so-called stimulants. If the system appeared to be in a state requir-
ing them, we should sanction their use without any reference to the
causation of the disease. If there appeared no necessity for them,
we should certainly forbear them. With regard to the expectant
method, we have no doubt that it will afford better results than any
blind routioe treatment, but we fully believe that a well-directed
medication is far preferable. We cannot think it a matter of
indifference whether a patient is allowed to go on raving for a week
or more until sleep naturally comes, or whether he is speedily calmed
and put to sleep. Nor do we think it can be other than injurious
to allow a patient to continue for days with his brain in a state of
semi-inflammatory excitement, when we have positive evidence of
the power of tartar emetic to control it. In most diseases it is better
to trust the unaided powers of the " vis medicatrix" than to interfere
blindly and rudely, but this does not lead us to conclude that medi-

1 "Madras Q. J. of Med. Sc," July, 1863.

2 "Australasian Med and Surg. Rev.," vol. i.

3 " Med. T. and Gaz.," Aug. 24th, 1861.

122 DELIRIUM TREMENS.

cine is useless or pernicious, but rather that its exercise requires not
seldom considerable skill and judgment.

The following cases were treated with full doses of henbane, and
as it seems with benefit.

No 32. — J. H., set. 33, ad. September 16th, a robust, vigorous-lookiug
man. He had been under Mr. H. Smith's care, who kindly gave me the
following particulars respecting hira. For the last year he has been in a
very excited state, at intervals drinking to excess spirit, beer, and large
quantities of port wine. Generally after these bouts he has been exceedingly
violent, so that his wife has beeu. obliged to fly for her life into the street.
He has no sleep at night sometimes for a fortnight, has strange fancies about
the inconstancy of his wife. He has always been eccentric, and has an uncle
who is said to be out of his mind and subject to fits. Some time ago he had
a fit of apoplexy and has been more excitable since. The cause of his last
attack was its being hinted to him by a malicious woman that his suspicions
of his wife were well founded. He became extremely excited and violent,
broke all the furniture in the house, and threw the milk (he is a dairyman)
into the street, &c. Mr. S. on being called in gave him tr. hyoscy. 5ij
+ spt. £eth. chl. Tr\,xx, mist, camph. ^ij at once, and an .li more of tr.
hyoscy. in the next twelve hours. He was calmer afterwards, but did not
sleep. The next day he was very outrageous and was removed to the hospi-
tal, where he came under my care. He was not violent then. Pulse quick.
Skin moist. Tongue coated. A good purge of calomel and jalap was given,
and in one hour after gr. xv of extr. hyoscy., after which he slept for two
hours. He had not slept before for three or four nights. The next day he
had 5ss in three doses, and as much the day after, the pupil became dilated,
and the throat quite dry. He was very fairly quiet immediately after the
first dose of henbane^ slept well on the night of 19th, and was quite recovered
by the 21st. It seems to me pretty certain that this man was tranquillized
to a great extent by the henbane, and that it was of great value in thus pro-
curing the gradual subsidence of the cerebral disorder. He had on former
occasions been fourteen days without sleep, and now he was convalescent in
about half the time.

No. 33. — J. G., £et. 45, ad. May 31st. A strong-made broad-chested man,
an habitual toper. Has j-ecently attempted while intoxicated to cut his
throat, did not lose however much blood. He had no delirium tremens
when admitted, but on June 1st, in the evening, he became suddenly very
violent, and has been intermittingly so since, being rational by day, but
towards evening becoming violent. This has been the case the last three days ;
he was worse last night than at any time before; the delirium lasted from 12
to 3 A. M., was calmed by tr. opii Jss + ant. pot. tart. gr. ^, Atis horis.
Is now (June 4th) quite rational and quiet, did not sleep last night, but did
the one before. Pulse of moderate force, head not hot. Has porter Oij
daily. Ordered extr. hyoscy. gr. xv at 4 P. M. 5th. Went to sleep soon
after taking the pills and slept all night ; is rational and comfortable this
morning. 6th. No delirium, slept well last night. Tongue dryish and red,
taking since yesterday bark + ammonia + chloric ether 4/?'s hor7's. Pills
given Alis horis till 6 P. M. yesterday, but they made him very sick after
about that time 8th. No return of delirium, takes food well, slept well
last night. Takes extr. hyoscy. gr. v, o. n., and the tonic. 18th. Discharged.

TETANUS. 123

CHAPTER XI.

TETANUS.

The state of excitement of the spinal cord constitutes the disease
called tetanus. It seems to me impossible to regard this otherwise
than as a functional disorder, although I am quite aware of Demme's
researches confirmed by Flechner and others as to the presence of
new growths of connective tissue in the cord in various fatal cases
which they examined. It seems to me by no means improbable that
this new formation was rather the result than the cause of the dis-
ease. Just as the Pacchionian granulations result from repeated
excitement and hypersemia of the brain, so we may believe that a
condition of violent excitement of the cord would very probably lead
to some similar effusion in its substance. Moreover the same fibroid
formations have been met with in cases of ataxic locomotr., a very
different disease. The unpractical character of Demme's results
appear in his recommendation of pot. iod. as a remedy more likely
to be useful in tetanus than any other. This will hardly meet with
the assent of any experienced man. The functional nature of
tetanus appears also from its being induced by the poisonous action
of strychnia, which, according to the testimony of Todd and Bowman,
produces no discoverable change in the nerve tubes and cells of
animals killed by it. The curative action of aconite which appears
to be the physiological opposite to strychnia may be cited as having
the same import. The tolerance of this drug in tetanus is very
remarkable, and clearly shows that the system must be in a very
opposite state to that which it induces. The effects of long-con-
tinued heat as a predisposing, and of exposure to cold as an exciting
cause also go to show that the disease is essentially functional.
These are common causes of nerve disorders, and it is not surprising
that they should be of this. Heiberg^ concludes that tetanus is not
a nerve disorder, but an affection of the blood localizing itself in the
muscles. This localization expresses itself by deposits in the
muscular tissue and metamorphosis of the same probably directly
induced by altered or diminished innervation. The immediate result
of this is shortening and stiffness of the muscles; the tetanic convul-
sions are consequently not spasms, but contractures. The reflex
spasms which he admits do occur are only accidental, and do not
belong essentially to the disease. He compares the disease to
diphtheritis, and recommends the local application of argenti nitras,

• "Norsk Magaz.," xv., 1861.

124 TETANUS.

or iodine naphtha, or nitromuriatic acid baths. A theory which
seems much more probable than Heiberg's, maintained bj Richard-
son, Roser, Wells, Thomson, and Betoli, regards tetanus as the
result of a poisonous matter formed in the blood, or absorbed into it
from an unhealthy secretion of the wound. This acts like strychnia,
setting up that peculiar irritable state of the cord which is the
essential condition of the phenomena, and without which the various
slight excitants which produce the spasms would take no effect. The
supporters of this theory justly insist on the prime necessity of
accounting for this condition of exalted polarity, which they think
can hardly be explained on the sole view of peripheral irritation.
They insist further that it gives an explanation of the idiopathic
form, and of the occasional epidemic or endemic prevalence of the
disease. They notice also the close resemblance between hydro-
phobia, a disease undoubtedly of toxic origin, and tetanus. It may
also be added that division of the nerve proceeding from the seat of
the injury in traumatic tetanus has by no means proved so fre-
quently successful as one would expect on the view of peripheral
irritation being the sole and essential cause. There is much in this
theory to commend it, but until it is proved that any secretion of a
wound can on being inoculated give rise to tetanus it must remain
a mere hypothesis. We have no example of any similar morbid
production setting up notable nerve disorder. In glanders and
farcy, in malignant pustules, in pyaemia, in syphilitic and smallpox
inoculation, and in the action of snake poison, the phenomena are
much more those of disordered circulation and blood crasis than of
nervous derangement. It is certainly extremely rare if it ever
happens that a foul ulcer, not the result of traumatic injury, becomes
the cause of tetanus.

On the other hand, the theory which assigns to local irritation the
chief place in the causation of the disease has, especially if some-
what modified, much evidence in its favour. The well-known greater
tendency of lacerated wounds to be followed by tetanus is very
strongly shown by Mr. Poland's figures. He states that at Guy's
Hospital the disease occurred only in 1 case out of 1364 when the
wound was made by a clean sharp knife, but in 1 out of 55 when
the nerves were injured as in accidents. Dr. Macleod^ relates two
cases of fatal tetanus in which the spasms were almost entirely
limited to the side injured. It is clear that in all cases a certain
predisposition of the cord must exist before the spasmodic symptoms
declare themselves. As Dr. Watson says, " the real mystery lies
in this predisposition." It will tend to throw some light on this
dark subject if we look at some of the points of aflSnity between
tetanus and other nervous disorders. Prolonged exposure to heat
is known to have a considerable influence in promoting the occur-
rence of tetanus, and. that it enfeebles the nervous system and

' "Notes on Surgery of Crimean War," 1858, pp. 165 — 161.

TETANUS. 125

renders it more liable to a variety of derangements is also notorious.
Exposure to wet and cold is a recognized cause of tetanus, and from
a history recorded by Maisonneuve we learn that it may produce
epilepsy. Eighteen sailors after escaping from the enemy by swim-
ming to a rock were for seven days exposed to great privation and
severe cold ; four weeks after they had been received into a hospital
they were seized with epileptic attacks, and in twenty-eight months
fourteen died. The action of cold in producing cramp, sometimes
pretty severe, even in healthy persons, is a familiar fact. It has
caused the death of swimmers. There can hardly be any question
of poison here. Yet cramp is a minor tetanus. When tetanus
supervenes on exposure to cold and wet, this is perfectly analogous
to the invasion of paralysis under similar circumstances. Such
paralysis as we have seen is of inhibitory, and therefore of functional
character. It is true there is a wide difference between the two
results, between the spasmodic and the paralytic affection, but there
is much to justify the view that both may be varieties of deranged
action of nerve-cells. Just as numbness and pain, which are cer-
tainly very different sensory disorders, are co-products ef the cause
giving rise to neuralgia, so it may be with spasm and paralysis. In
a case of brachial neuralgia now before me the patient suffered at
night after about two hours' sleep with unbearable pain and com-
plete stiffness of the hand. This was the case after any hard work,
but when she had a quiet day she experienced only numbing and
tingling pain at night. The affection yielded to quinine and iron.
If prolonged action of our muscles causes fatigue, the same when
one position is maintained for a long time causes cramp. These
facts go to show that causes producing impairment of nerve-power
may give rise to spasm. To the same effect is a case recorded in
the Brit. Med. Journ., Nov. 29th, 1862, where it is stated that the
removal of an osseous nodule from the right thyroid of a young
woman cured her both of aphonia and dysphagia (palsies), and also
of a spasmodic affection of the arm. In some instances of non-
organic paralysis there is rigidity of one limb and simple immobility
of the other on the same side, the same cause having given rise to
both conditions, and the same treatment removing them. V.
Moodeen SheriiF, on Contraction or Kigidity of the Muscles in
Paralysis ; 3Iadras Q. J. of Med. Sc, April, 1863.

The following history is of much interest in many respects, and
especially as showing how an influence which generally tends to
enfeeble and paralyze may produce an (apparently) opposite effect : —

No. 34.''— Mrs. S., £et. 22, had had "dead ague" a little before April,
and expected her second confinement in July. At the age of 14 she had
fits brought on by excessive fright in which she had bitten her tongue. April
19th. She had a severe seizure of emprosthotonos, the limbs and trunk
being in a state of rigid spasm, and the hands firmly clenched. This lasted

' "Lancet," Sept. 27th, 1862.

126 TETANUS.

half an hour, and then changed to opisthotonos, which lasted three-quarters
of an hour. Severe congestive head-pain followed the attack. She was
purged with calomel, took quinine, and the next attack was much modified
as well as the consequent congestive headache. One or two other attacks
occurred from neglecting precautions, but by taking quinine, and attention
from time to time future ones were averted. She went her full time and
was delivered of a living child. Before the first attack she had previous
threatenings on two or three consecutive days, and always at the same hour.
The district is malarious. Rabe* has recorded the case of a child four months
old, who had epileptic convulsions and hemiplegia of the right side with
deafness of that ear, and distortion of both eyes to the left. Otorrhosa ex-
isted, but the membrana tympani and the walls of the meatus were not
materially injured. All these symptoms ceased after the removal of the
body of a centipede from the auditory meatus. A similar case is recorded
by Fabr. Hildanua, where a piece of glass in the same situation gave rise to
similar phenomena. Here we have examples of the production of spasm and
paralysis by the same cause in the same system.

Chorea, which seems to stand intermediate between tetanus and
paralysis, is sometimes excited by terror like the former. Epilepsy,
like tetanus, requires a certain predisposition, a peculiar irritability
of certain nervous centres. Without this, exciting causes known to
produce the disorder fail to take effect. The case which Pfliiger
quotes from Dieifenbach shows that a tetanoid state of one arm, and
general epileptic paroxysms may be co-results of the same traumatic
irritation, and cease with its removal. This indicates that the mor-
bid condition in both is diathetic rather than toxic. Dr. Prichard^
states that conversions of chorea, epilepsy, and paralysis are by no
means rare occurrences. He cites a case he saw himself of a child
who three years ago had pertussis, and the fits of coughing threw
her into paroxysms of tetanic epilepsy. These symptoms subsided
after continuing some months. She was next seized suddenly with
hemiplegia of the right side from which she nearly recovered, but
is now troubled with chorea of the same parts. I had recently under
my care a girl, get. 16, who suffered from a severe abdominal neu-
ralgia, and occasionally from fits of unconsciousness. I saw her in
one of these, and found both lower and the left upper limb quite
rigid. Under tonics and sedatives she recovered. It deserves I
think to be considered that the muscular contractions in tetanus are
attended with severe pain, the pain of cramp. JSTow this shows of
itself that they are very different from voluntary muscular contrac-
tions, which how forcible soever are never painful. The association
of pain approximates the nerve disorder to neuralgia.

The case related by Swan seems to put in a clear light the influ-
ence of an injury in inducing tetanus. The patient, a female, had
been operated on for popliteal aneurism by opening the sac, and
applying a ligature above and below it. Everything went on satis-

' "Gaz. des Hopit.," 123; 1861.

2 "On Diseases of the Nervous System," p. 64.

TETANUS. 127

factorily until one day the attempt was made to change the position
of the limb from the flexed to the extended, when the patient uttered
a tei'rific scream, was soon after attacked with tetanus and died.
At the post-mortem it appeared that the cutaneous nerve which
accompanies the lesser saphenous vein had been divided in the ope-
ration, and that the upper end which had become adherent to the
surrounding parts had been abruptly separated in the attempt at
extension. Romberg, who quotes the case, weakens its force by the
remark that tetanus must have been already making its approach ;
but I think this is not a fair comment on the facts. The case seems
to be an example of the effect of shock. Langenbeck' records three
cases which go to prove that tetanus may be dependent on local irri-
tation. In the first he removed by an incision the fragment of a
needle, the symptoms immediately lessened, and next day the patient
was well. In the second removal of a ligature from the spermatic
cord, which had been tied en masse after castration, at once stopped
all the symptoms. In the third case the reduction of a fracture
which was attended with great displacement had the desired effect.
In examining any case of tetanus we ought to bear in mind the
investigations of Froriep,^ who found in seven cases the nerves pro-
ceeding from the injured part to the spinal cord affected at intervals
with a peculiar inflammatory change, consisting in nodulated tume-
faction and reddening of isolated points separated from one another
by healthy tracts. He thinks these are peculiar to tetanus. Lus-
sana's statement'^ goes to confirm this, who makes one of the points
of diagnosis between neuralgia and neuritis that in the latter the
muscles are affected by severe and violent, continuous, tonic and
clonic, tetanoid contractions. Mr. Erichsen also says that he has
never failed to find the nerve running from the wound more or less
inflamed, and often for a considerable distance, whenever it has been
carefully looked for. The nature of the effective cause in some
cases of tetanus makes it most highly probable that no poison was
concerned in its production. Such injuries as the blow of a whip-
lash, the bite of a finger by a sparrow, the cutting of a corn (Wat-
son), can scarcely be supposed to have any toxic action. To give
this argument more weight it should be contrasted with the circum-
stance that the most various kinds of ulcers so far as I am aware
never give rise to tetanus. Syphilitic sores primary and secondary,
tuberculous cavities, the intestinal ulcerations of typhoid fever and
dysentery, varicose ulcers of the legs rarely if ever have this result.
Yet it is surely probable that a poison might be generated in them
which would give rise to tetanus if this were the true pathology of
the disease. Moreover, in various cases tetanus has commenced
some time after the wound, which may have been but a slight one,

' "Med. Centr. Zeit.," 1862, No. 34; " Syd. Soc. Year-book," 1863, p. 220.

* V. Romberg, vol ii. p. 104.

' Prize Essay, Milan; Scbmidt's "Jahrb.," vol. cviii. p. 168.

128 TETANUS.

has healed. The general bearing of all this seems to be that the
influence of shock, or irritation, or of some morbid surface impression
is much more potent in producing the disease than any condition
■which might generate a poison. The acknowledged influence of
sudden variations of temperature, of mental emotions, and of certain
epidemic constitutions in producing tetanus, seem to me to approxi-
mate it much more to maladies depending on imponderable agencies,
than to the so-called zymotic. Trousseau describes under the name
of tetanilla a disease allied to tetanus, and which in grave cases
passes into it. It consists in contraction of the hands, arms, or
lower limbs, one or all being aff'ected, but the upper being usually
the first to suffer. The attacks are preceded by formication, anaes-
thesia, and impairment of voluntary power in the limbs, and are
attended with more or less pain extending along the principal nerves,
and radiating sometimes into the trunk. In grave cases the whole
body becomes involved, and there is some amount of pyrexia. It is
characteristic of the disorder that the spasm commences in the limbs,
and extends subsequently to the muscles of the trunk and neck,
contrary to what occurs in tetanus. Further the muscles of the
limbs and those of other parts are seldom attacked at the same time,
and what is specially distinctive is that the contractions can be
brought on immediately by compressing the nervous trunks or the
vessels of a part. The most effective causes of the disease are lacta-
tion, diarrhoea, attacks of cholera, and of enteric fever, and exposure
to cold. It is however remarkable that the application of cold to
the contracted parts often immediately arrests the spasm as long as
it is continued. Trousseau regards the disease as of rheumatic
character. He finds bleeding from the arm or cupping along the
spine, where the strength of the patient permits their employment,
to have most efficacy. Quinine is the next most useful remedy, and
then follow opium and belladonna in small doses. In violent parox-
ysms chloroform inhalation may be cautiously used. Aran has
found the internal administration of chloroform beneficial combined
with its local application to the contracted parts.^

As to the therapeutics of tetanus, it does not matter which view
we adopt of the pathology of the disease. If the symptoms depend
upon a poison, we have no means of eliminating it, or destroying it
in the body. Our efforts are confined in this as in all other cases
of the same kind to counterworking the morbid action. Certainly
it will always be desirable to promote, as far as possible, a healthy
state of the wound if there be one, to correct a faulty state of the
secretions, and especially to provide for an ample supply of pure,
cold, fresh air. The importance of this in preventing pysemia and
hospital gangrene is acknowledged, and I am sure its sedative influ-
ence on undue nervous excitability can hardly be over-estimated. I
should be inclined to ascribe the recovery of the soldier whose case

* "Clinique Med.," vol. ii. p. 107.

TETANUS. 129

is related by Dr. MacGregor,' as much or more to free exposure to
the fvesh ah', as to the effect of cold, which, except under proper
management, is apt to be injurious. Cold aifusion, however, is said
to have proved useful, and Dr. Todd recommends the application of
ice along the spine. Carpenter^ affirms that he cured sixteen out
of seventeen cases by this means. Probably the cold douche would
be beneficial. Careful examination of the wound should be made
to detect any foreign substances which might be lodged in it, and
act as a cause of irritation. A highly interesting case has lately
been recorded by Mr. Wood^ where division of the internal saphenous
nerve, which was irritated by a comminuted fracture of the leg,
arrested permanently the tetanus which had set in two days before
with severe convulsion. Dr. Fayrer, of Calcutta, divided the median
nerve in a case of wound of the hand with decided advantage."
Should any evidence of neuritis be discovered in the course of nerves
proceeding from the injured part', this state should be the object of
treatment. The exhausting nature of the disease should be kept in
mind from the first, and wine and nourishment should be freely ad-
ministered. Among the special means which may be employed in
the view of subduing the abnormal excitability of the cord there are
but very few that have any real chiim to notice. Recoveries have
taken place under many, but the share of the drug in the recovery
is open to question. With regard to the angesthetics, chloroform
and ether, Thamhayn^ reports that they certainly afford considerable
temporary relief. The pulse falls to its normal frequency, and the
breathing becomes regular. The spasms and the concomitant pains
vanish, as well as the distressed expression of the countenance, and
tranquil sleep ensues. The external appearance of convalescence
is complete, but all the while the disease is powerfully and insi-
diously advancing onwards towards its fatal termination. Its course
is not delayed, nor its intensity diminished. As soon as the remedy
is omitted the whole array of fatal symptoms reappears. Often the
intensity of the disease, and of the pain is proportional to the time
during which both have been suppressed by the anaesthetic. Saurel's
report is in a much more favourable strain; he states that he has
procured recovery in 29 cases by chloroform or ether, 11 of them
being idiopathic, and 18 traumatic. He thinks the chief cause of
failure lies in having recourse too late to these remedies. The pos-
sibility of restoring the power of swallowing by these means is cer-
tainly a great gain. The conclusions arrived at in a report on 43
cases in the Medical Times and Crazette, June 17, 1854, are nearly
to the same effect as Thamhayn's. The writer states that the con-
tinuous administration of chloroform over long periods of time is

' He had Tiolent tetanus from a slight injury, and was carried for sixteen hours
exposed to severe weather. On his arrival at the halting-phxce he was half-frozen to
death, but the tetanus had disappeared.

2 New York J. of Med., January, 1860. 3 Brit. Med. J., July 4, 1863.
■ * Brit. Med. J., Oct. 10, 1863. 5 Schmidt's Jahrb., vol. cxii., p. 210.

9

130 ' TETANUS.

not to be recommended, since the patient sinks as fast at least, if
not faster, than when the disease is allowed to display itself. There
is some ground for believing that ether gives more favourable results
than chloroform. With regard to the various narcotic drugs which
have been employed, it appears from a review of the cases recorded in
various journals during the last four years that aconite and nicotine
are the most successful. Woorara shows only two recoveries out of
eight cases in which it was tried. One point which seems note-
worthy is the great tolerance of aconite which is produced by the
disease, a dose being well borne during its continuance, which proves
poisonous when it has passed away. The aconite may be given at
the rate of i^lxv of the tincture (Pharm. Brit.) 4tis Jioris, of course,
watching carefully its effects. It is as well to give it with a stimu-
lant, as in brandy-and-water, to obviate its depressing effects on the
heart's action. Some systems are extremely susceptible of its toxic
effect. I am acquainted with an instance where so small a quantity
as half a drop of the Pharmacopoeia tincture (1851) applied to the
mucous surface of the lower lip produced distinctly poisonous symp-
toms, which continued nearly twenty-four hours. The dose of ni-
cotine varies from ^ij to ^ijss, given from four to six times a day,
according to the urgency of the tetanic spasms. Its effects are
stated to be lowering of the pulse, in one case from 130 to 88, in
another it caused an increase of 10 beats; immediate relaxation of
the spasm of the muscles of expression, respiration, deglutition, of
those of the back and of the abdomen ; cessation of delirium and
feeling of relief from agonizing pains ; profuse sweating with an
intolerable odour of snuff; tendency to sleep. The hamstring and
abductor muscles were more refractory to its influence than the
others. Mr. TufnelP records a case of severe traumatic tetanus in
which 56 drops of nicotine were given in six days. Chloroform
had been given by the mouth for three days without benefit. The
nicotine certainly seems to have been beneficial, but had ultimately
to be given jjer anu7n owing to the disgust it produced. The teta-
nus ceased in fifteen days. The reporters of the Medical Times
and Gf-azette, April 6, 18G1, recommend the free use of quinine in
all except the most acute cases. The bowels should be effectively
acted on once.

The diet should be such as to support the strength ; easily-digesti-
ble food and wine should be administered at short intervals. Trial
should be made in all cases of the continuous galvanic current trans-
mitted along the spine. A Pulvermacher's chain of 120 links may
be used, or a series of 15 to 20 cells of Daniell's battery. Of course
it is not to be supposed that more than a very small part of this
current actually reaches the cord, which lies so surrounded by moist
tissue capable of transmitting electricity, and this is a reason for
employing a larger battery than would be requisite if it were possi-

i Dublin Med. Press, Jan. 7, 1863.

CATALEPSY. 131

ble to act on the cord directly. It appears that the direction in
which the current is passed is of no importance. Dr. Radcliife
states that if a frog be poisoned with strychnia it is possible to pre-
vent the development of the characteristic spasms, or to suspend
them after they have actually commenced, by subjecting the spinal
cord of the animal to the action of a continuous galvanic current.
Moreover, Matteucci refers to the case of a man suffering from
tetanus in which the patient was able to open his mouth, to breathe
freely, and to move his body and limbs without much difficulty so
long as a strong galvanic current was made*to pass continuously
along the spine from the occiput to the sacrum.

As regards prognosis, the following may be stated. The later the
disease commences after the infliction of the injury the more hope
there is of recovery. Prolongation of the disorder is generally
hopeful, but it has been known to terminate fatally after fourteen
months (Meadow's case).' Continued difficulty of swallowing or
hindrance to respiration are perilous signs — death mostly occurring
from exhaustion or asphyxia.

CHAPTER XII.

CATALEPSY.

This rare and curious affection doubtless belongs to the family of
functional nervous disorders. It occurs chiefly in those who have
weakly and excitable nervous systems, feeble health, and ill-governed
minds, and who may be said to possess neither a "mens sana," nor
a " corpus sanum." In fact many subjects of these disorders claim
more properly the care of the alienist than of the ordinary physi-
cian. At least it may be said that after the cessation of the actual
attack judicious moral treatment will almost invariably be of as
much, if not more consequence than medical. One case is however
recorded^ where it seems to have resulted from an intracranial epi-
thelioma. As regards the nature of the disorder it may be said
that it is evidently allied to tetanus, but differs in the circumstance
that the brain is involved as well as the cord, and that consciousness
is more or less in abeyance. In a case very ably recorded by Mr.
Jones^ it is stated that all the muscles of the extremities and of other
parts were so rigid that they could not be moved for two or three
hours, and in three other cases which he refers to occurring under
the observation of others the same symptom was well marked. " The
extreme degree of rigidity," he says, "generally exists about the

' " Medico-Chir. Trans.," ISfll. 2 Canst. " Jahresb.," 1861, toL iii. p. 77.

3 "Brit. Med. J.," June 6, 1863.

132 CATALEPSY.

commencement of the attack and passes off before the termination."
Recently an account has been published' of an endemic cataleptic
disorder prevailing at Billingshausen near Wiarzburg. The popula-
tion consists of peasants who are well off, but Avho intermarry very
much, and are all small and deformed. The affected individuals
constitute half of the number, males as well as females. They are
called there "the stiff" ones" {starrefi). A chill is commonly said to
be the exciting cause of the attacks. The patients are suddenly
seized by a peculiar sensation in their limbs, upon which all their
muscles become tense, their countenances deathly pale, they retain
the posture which they first assume, their fingers are bent and quiver
slightly, and the eyeballs in the same way, the visual axes converg-
ing ; their intellects and senses are normal, but their speech con-
sists only of broken sounds. The attack ceases in from one to five
minutes, and the body becomes warm. The indications of a tetanoid
affection are very evident here both in the arterial and in the volun-
tary muscles, and the same is true of the following case recorded by
Mr. Austen.^ " A male, the subject of large delusions and markedly
dilated left pupil, having once apparently recovered was readmitted.
He was now depressed •and apprehensive. On the sixth day he
became heavy, and was got to bed with difficulty. Half an hour
afterwards he was completely comatose and motionless ; the pulse
was scarcely perceptible, and could not be counted. A salt injection
having been given, he was placed on the night-stool, and then it was
at once discovered that he was cataleptic. His limbs remained
exactly as the attendant left them ; his figure without support was as
erect as a statue. The legs and arms were put in positions the least
convenient and the most opposed to gravity : thus the legs were ex-
tended straight from the hips, and the arms at right angles to the
thorax. In tjiis singular state and posture he remained a quarter of
an hour, when suddenly the enema operated, and the utensil was
filled with an immense number of hard fecal lumps. The pulse on
the instant rose, the rigid limbs fell, and the statue vanished. In
twelve hours he was sensible, and understood questions. In thirty-
six hours he was walking about as usual. This case illustrates ex-
cellently the effect of intestinal irritation in producing quasi-tetanic
affection of the voluntary muscles, spasm of the cerebral arteries,
and probably of the radial. If the latter was not the case, there
must have been inhibitory depression of the heart's action. Either
might result from reflected morbid stimulus. In the Billingshausen
cataleptics it is pretty certain that spasm of the branches of the
external carotid existed during the attacks, but not of those of the
internal. In other instances, according to Dr. Copland, there is evi-
dence of active congestion of blood in the head. In any case as in
Mr. J.'s where sudden complete unconsciousness with tetanoid
rigidity of muscles occurred I cannot think that the brain could be

' Schmidt's " Jahrb.," vol. csx. p. 301. ' Austen on General Paralysis, p. 55.

CATALEPSY. 133

otherwise than an?emic. In a case recorded by Dr. Bellingham
{DiihJin 3fed. Press, July 8. 1846) a female, £et. 18, amenorrhoeal,
had for more than six months daily fits in which the cheeks were
flushed, the limbs almost tetanically rigid, the pupils mobile, the
heart's action violent, pulse 120, respiration tranquil. There was
complete unconsciousness and loss of voluntary motion, no recollec-
tion of what occurred during the fit. After the first ten minutes of
the attack the tetanic rigidity diminished, and the limbs could then
be placed and retained in any position. She w^as cured by leeches
to the nares, purgatives, spt. ammon. foetid., and shower-baths.

In the three cases to which Mr. Jones refers consciousness Avas
but partially abolished, and the same is true of his own case. The
degree of unconsciousness may vary with the degree of anaemia of
the hemispheres which is produced. In two of these cases the
temperature was not materially altered, in one the surface every-
where was of icy coldness, the countenance pallid, and the muscles
were rigid as iron, while the pulse was of fair strength. The patient
•was a stout male, well made, but of nervous and excitable tempera-
ment. He had two attacks exactly of the same kind at an interval
of about eleven months, both of which were brought on by the same
conditions, viz., excitement, fatigue, and want of food. They
subsided after lasting about twenty-four hours by means of rest,
•warmth to the feet and the epigastrium, and an opiate (in one).'
On two subsequent occasions after a day of unusual fatigue he
became very restless and troublesome, very stubborn, and partially
insensible, but had no cataleptic symptoms. He was soon restored
by rest and an opiate. I have cited some of the details of this case
because they seem to illustrate very well how causes of exhaustion
may give rise to excitement and violent muscular action instead of,
as they ordinarily do, producing languor and prostration. In this
young man on four several occasions the same cause was followed
by the same or similar effects, the chief diiference being that the
brain alone appeared to be affected in the two last. In the chapter
on Tetanus I have remarked on some facts analogous to the above,
and will only add here that they are all probably ultimately refer-
able to the general law that debility of nerve-tissue often coincides
"with increased excitability.

Catalepsy evidently is a disorder intermediate between epilepsy
and tetanus, "with both of which it has affinities. It resembles very
much the variety of epilepsy termed tetanic. The peculiar qualities
of nervous tissue in different individuals which determine the special
form and manifestation which dynamic disorder shall assume are far
beyond our observation. One thing, however, we can see, viz., that
much depends on which group of nervous centres most readily takes
on morbid action. If it be the spinal, we have tetanus ; if the medulla
oblongata and adjacent superior region, we have epilepsy ; if the

1 Case of Catalepsy by J. Buclianan, Esq., Glasgoiv Med. Journ., 1857, 1858.

134 EPILEPSY.

mesocephale alone, we have so-called hysteria ; if the hemispheres
alone, we have "le petit mal" of epilepsy, or " congestion apoplecti-
forme c^r^brale." Two or perhaps more of these centres may be
affected simultaneously and the resulting disorder will be complex,
which appears to be the case in catalbpsy.

Treatment must have for its object the removal of existing excit-
ing causes (as in Mr. Austen's case), and the calming of nerve
irritation. The latter will in some instances be best effected by
sedatives, in others by diffusible stimulants. In conditions of great
rigidity and coldness of surface a warm bath, or still better wet
packing would be I think very beneficial. In prolonged cases
galvanism should be employed, and I should prefer using the con-
tinuous current first. In Mr. J.'s case the interrupted current
materially diminished the rigidity of the muscles, but the cold douche
was rather injurious.

CHAPTER XIII.

EPILEPSY.

There can be little question that epilepsy is primarily and essen-
tially a functional malady. Graves records a case of great severity
in which idiocy and paroxysmal mania had supervened for years
before death, but where not the slightest deviation from the normal
condition of the brain and cord could be discovered on a very careful
post-mortem examination. It is true that minute microscopic
research was not employed, but I more than doubt whether this can
be trusted to detect changes which give no sign of their presence to
the experienced eye. When it is apparent that some kind of change
has taken place the microscope may give us most valuable aid in
determining the nature of that change, but I am not inclined to
trust it for much more. The various alterations which have been
found in the cerebral hemispheres and their membranes, the indura-
tion of the white substance, the adherence of the gray to the invest-
ing pia mater, the dilatation of the bloodvessels, &c., are certainly
rather consequences than causes of the paroxysms. One of the most
recent and successful investigators of this disease, Schrceder v. der
Kolk, states that we " have sufficient reason to conclude that the
first cause of epilepsy consists in an exalted sensibility and excita-
bility of the medulla oblongata, rendering the latter liable to dis-
charge itself on the application of several irritants, which excite its
involuntary reflex movements." Even when commencing dementia
has shown itself, as evidenced by a high degree of silliness and
dulness, complete recovery may ensue.

EPILEPSY. 135

The causes -wliicli induce epilepsy are partly physical, partly
immaterial. A great number of lesions about the head and even in
remote parts are known to have given rise to the disorder. Such
are injuries to the cranial bones, cicatrices of the scalp, tumours in
the meninges, wandering wisdom-teeth, worms in the bowels, calculi
in the ureter, or bile-duct. The disease originated in this way is
termed eccentric. It should, however, be clearly understood that
these physical excitants are by no means mere provocatives of the
paroxysms, the convulsions being supposed to ensue as the reflex
results of irritation, but that they actually set up in the nervous
centres that state of excitability which is the essence of the'disorder.
They are therefore both predisposing and exciting causes. They
require, however, a certain amount of predisposition in the nervous
centres to become operative. In many individuals the quality of
these centres is such that the morbid impression fails to take effect,
they are proof against it. In others, and this is very remarkable,
the same cause which might have induced epilepsy has a different
result. Thus intestinal worms may cause paraplegia or amaurosis,
a neuroma may cause only severe neuralgic pain, and an exostosed
wisdom-tooth permanent infra-orbital neuralgia. Causes of centric
epilepsy are the following : Poisoning of the blood from retention
of excrementitious matter. This by deranging the nutrition of the
nervous tissue generates the abnormal excitability which then mani-
fests itself without any special irritant. Various causes of exhaus-
tion, such as hemorrhage and excessive discharges, venereal excesses,
prolonged want of sleep, unremitting pain act very much in the
same way. Sudden fright seems to rank rather higher as a cause.
Copland indorses Esquirol's statement that fits of passion, distress
of mind, and venereal excesses hold the next rank to terror in excit-
ing the disease. This shows the relation of the malady to chorea,
which is so commonly produced in the predisposed by fright. Grief,
prolonged anxiety, the sight of a sufferer in the paroxysm, and in
fact almost any very powerful mental emotion may give rise to
epilepsy. From the above facts one conclusion of much importance
may, we think, be deduced, viz., that epilepsy is for the most part a
diathetic, and not a toxic affection, and that the elimination of a
materies morbi is not to rule our therapy. The effective causes are
mainly those which produce dynamic derangement, and which so far
as we know can generate no poisonous matter.

There is one condition which has not yet been mentioned, and
which according to my experience is rather infrequent, but which
Copland declares to give rise to the most common form of cerebral
epilepsy, especially in this country. I refer to sanguineous plethora.
Prichard also in the interesting cases he relates, found repeated
venesection so often of essential service that one cannot doubt that
an excess of the circulating fluid may be a vei-a causa of the disease.
Schroeder v. der Kolk's experience is nearly to the same effect.
Copland says that he has found the disease most frequent in persons

136 EPILEPSY.

■who were either very plethoric, or very much the reverse. My own
observation leads me to the contrary opinion, I should certainly say
that the epileptics I have had to deal with have been of a medium
temperament, neither sanguine nor anaemic. With regard to indi-
viduals in the latter state, I have often remarked their freedom from
epileptic disorder. In some exquisite instances of anemia there has
been nothing of the kind. With respect to local plethora, i. e.,
determination of blood to the head, the case is different. This is
often associated with very marked debility, and seems indeed to a
great extent dependent upon it. The vaso-motor nerves of the
cerebral arteries participating in the general weakness become
unable to keep the vessels properly contracted, in consequence of
which a relative excess of blood is sent to the encephalic centres,
and produces a state of excitement. In some cases the local deter-
mination of blood may be due, at least in part, to the state of excite-
ment of the nervous tissue induced by other causes, and which then
attracts dfronte an undue amount of blood to the part. The condi-
tion here is similar to that which exists in .some cases of retinal
hypersesthesia, where the morbid excitability is complicated with
and aggravated by a degree of hypersemia. The state in fact is one
of semi-inflammatory nisus.

The irritating effect in certain conditions of an excess of blood
coursing through a tissue has not, I think, been sufficiently con-
sidered. It was excellently illustrated by Vanzetti in his observa-
tions on inflamed limbs, where the inflammation was found to subside
permanently after the main artery had been compressed for about
twenty-four hours. The following remarks seem to me to set forth
the pith of the matter. The circulation of arterial blood not only
maintains the nutrition of the several tissues, but also acts as a sus-
taining stimulant to their vital powers. Of this I think we can be
sure from the phenomena attendant on embolism. A patient is
attacked suddenly with violent pain in the left groin, " exactly as if
he had been shot." From that moment, so runs the report,^ the
limb became numb, cold, and quite powerless, and pain continued
intense for some hours, at least twenty-four. Death occurred from
gangrene in thirty-seven days, and an embolon three-quarters of an
inch long was found in the femoral artery two inches below Poupart's
ligament. Now, as the muscles and nerves of an amputated limb
manifest their functional power for some short time after its removal,
we are sure that the powerlessness in the above and in similar
instances did not depend on any immediate abolition of contractility
and of vis nervosa, but on an impairment of these vital faculties, so
that the organs were unable to respond to the stimulus of the will.
Kussmaul's and Tenner's conclusion, that the brain of a rabbit can
remain deprived of arterial blood for two minutes without losing its
capability of again performing its functions upon the renewal of the

1 "Lancet," June 7th, 1862.

EPILEPSY. 137

circulation, the convulsions ceasing immediately at the same time,
shows also that nervous centres retain to a considerable extent their
vital powers when deprived of blood. In cold-blooded animals this
independence of the tissues on continuous circulation of blood is much
more marked ; frogs and snakes will certainly perform voluntary
movements when circulation has ceased. From these facts, then, as
well as from the immediate arousing and exciting effect on the bi ain
of an increased flow of arterial blood, while its deprivation as rapidly
induces an opposite state, I conclude that blood is not merely a
nutrient to the parts it traverses, but also an excitant. Now in
plethoric states, whether general or local, this excitation may be
excessive, and the so-called excitable districts of the brain, the
medulla oblongata and the parts situated just above it, may be
thereby wrought into a condition of abnormal irritability, Avhich
bloodletting or checking of the blood flow may much relieve.

It is of much interest and importance to determine what is the
condition of the brain and nervous system for a short time before
and at the time of the paroxysms. This seems to have been pretty
well settled by observation. Dr. Copland's long list of premonitory
symptoms may be summed up in the statement that they all of them
indicate a state of abnormal irritability or incitability, associated
with a very varying condition of blood-flow, which may or may not
be in excess. The due and regular nutrition of the nervous centres
is evidently deranged. The aura with which the paroxysms some-
times opens is one of these nervous derangements. It is an ex-
tremely remarkable circumstance that interference with this aura
should in a certain number of cases enable us to arrest the paroxysm
which is on the verge of exploding. That the aura is really of cen-
tral origin can scarcely be doubted, its appearing to extend along the
nerves indicates only the involving of one central termination after
another. There is no sort of reason for supposing that there is any
peripheral disorder in the nerves which are its apparent seat, and'
where there is such disorder, as in neuralgia, it does not concur with
epilepsy. It remains therefore a very curious and suggestive fact
that we should sometimes be able to modify the vital state of a ner-
vous centre, and that too beneficially by acting upon the nerves to
which sensations of central origin are referred. Something of the
same kind has been observed in sciatica, and in other states.

Almost up to the moment at which the paroxysm commences the
circulation is not notably disturbed, but just at this time, according
to very accordant testimony, marked pallor of the face ensues,
followed by the shriek, the insensibility, and the convulsions. The
sudden complete insensibility of the "grand mal," the giddiness and
more or less complete though briefer unconsciousness of the " petit
mal" seem to me capable of being explained only by a suddenly-
induced anaemia of the hemispheres ; and the convulsions are, as we
know from Kussmaul's and Tenner's researches, necessary conse-
quences of the same state of the medulla oblongata and the meso-

138 EPILEPSY.

cephele. That the cerebral anaemia is not the result of mere syn-
cope we are sure. There seems then nothing left but to assume
that a sudden constriction of the cerebral arteries occurs. It is
highly probable that the greater the hyperasmia and excitability was
just before the attack, the more violently will the nervous centres
resent the succeeding anaemia. In the majority of instances the
cerebral anaemia is of short duration, and is immediately replaced
by a hyperaemia which at first is of venous character, both from the
retardation of the blood in the large veins, and also from the non-
aeration of the blood wdiich the left heart sends into the arteries.
As the respiration is restored the hyperaemia becomes arterial just
as was observed in Kussmaul's rabbits. This hyperaemia results
from dilatation of the vessels, which seems to be the natural sequence
to sudden constriction, as in the common reaction and glow which
ensues in healthy persons after the shock of a cold douche. That
the sopor depends chiefly on exhaustion is apparent from its absence
in cases where the attack consists in simple unconsciousness without
convulsions.

The foregoing seems to give a rational account of all the ordinary
instances of epilepsy, but it may be questioned how far it applies to
cases where the paroxysms are unusually prolonged. In many of
these the paroxysm is made up of a series of attacks separated from
one another by a longer or shorter interval of soporose exhaustion.
There seems no difficulty in understanding that the anaemia may
recur at the commencement of each, and that thus the same phe-
nomena are repeated again and again. It is impossible to deter-
mine how long the anaemia (which of course is not complete as it was
in Kussmaul's and Tenner's rabbits) may last, nor how long its
effects may continue to be manifested by muscular agitation. If
indeed the ansemia were immediately replaced by a moderate flow
of arterial blood, it is probable the paroxysm would rapidly be at an
end. But this is not the case in the fully-developed attack, the
disorder of respiration and the remora of the venous current fill all
the cerebral vessels with blood that is very imperfectly depurated,
and the disorder and commotion of the vesicular neurine continue
longer than they otherwise would. Much no doubt depends on the
quality of the nervous centres ; if they are highly irritable, and the
" vis nervosa" is considerable, the disorder will be more violent and
prolonged than when the reverse is the case. Thus, in the later
periods of the disease, when the brain has become more or less
damaged, the paroxysms are often less severe than at an earlier
date.

In all instances then of true epilepsy, I conceive a temporary,
more or less complete anaemia from spasm of the cerebral vessels,
to be the determining cause of the paroxysm, and to give it its spe-
cial features. Without this we may have various symptoms of cere-
bral irritation, but no epilepsy. A case recorded recently by Dr.
Palmer {v. p. 178) is surely an instance which might well have

EPILEPSY. . 139

assumed the form of enteric epilepsy, but inasmuch as there was no
tendency to arterial spasm the morbid phenomena took a different
direction.

It is however quite certain that long-continued convulsions may
be produced by the irritation of tubercles in the brain, by acute
hydrocephalus, by exanthematous miasm, and by certain poisons.
In such states there will be no spasm of the cerebral arteries, and
no consequent ansemia. The medulla oblongata and other parts of
the encephalon are directly irritated, and convulsion ensues, as when
the same parts are excited by the touch of the scalpel in a living
animal. The chief distinction between epileptiform attacks depend-
ing on direct cerebral irritation, and those occasioned by arterial
spasm lies in the paroxysmal and intermittent character of the one,
and the more continuous character of the other. In any given case
of course it will be essential to consider carefully the attendant cir-
cumstances, as the state of the urine, and of the bowels, the exist-
ence of any indications of intracranial disease, or of commencing
smallpox, &;c. In young adults we should not forget the possibility
of an errant wisdom-tooth being at the bottom of the disorder. The
case which I have given at p. 51 shows however that epilepsy, to
all appearance idiopathic and centric, may at its supervention persist
through so long a succession of paroxysms as to prove fatal by ex-
haustion.

It is a question not easy to decide how far arterial spasm without
any previous abnormal state of the encephalon may pe7' se give rise
to epilepsy. If the disease is ever produced in this way we should
expect to find instances of it among the manifold pranks of malarious
miasm, and it actually appears to be so. Mr. Lowe says/ " within
the last twelve months, many cases of jungle fever, contracted in
the Upper Godavery district, have been attended with severe epi-
leptiform convulsions." Dr. Payne^ has observed epileptic attacks
ensuing as the result of malarious infection, which may have oc-
curred long previously, and not have shown itself in paroxysms of
ague at any period. Cases of infantile convulsion are frequently
seen at Calcutta which stands in very close relation to malarious
epilepsy. In all of these quinine affords a cure. Payne considers
that a hydrsemic state of blood is the most important element in the
pathology of this class of disorder. Dr. Mackay^ recognizes the
occurrence of malarious epilepsy, and records a case of the kind, in
which the attacks were arrested by quinine. In some of Torti's
cases of lethargic pernicious fever the condition during the paroxysm
was not unlike that of the epileptic attack. In one case convulsive
movements occurred continually, and such a profound lethargy that
no kind of painful stimulation had any effect in arousing the patient.
The disease was cured by bark. Even in these cases, however, it is

1 "Madras Q. J. of Med. Sc," Jan. 1863, p. 67.

2 "Indian Annals," No. xiv. p. 597. 3 "Edin. Med. J.," Oct. 1863.

140 EPILEPSY.

not certain that the cerebro- spinal nervous centres were not to some
extent directly and primarily affected by the poison. Now that we
know so much more accurately the effects which are produced on
the brain by sudden arrest of the blood-flow, it seems to me that
very much of the mystery which has long attended on epilepsy is
removed. Indeed, so far from regarding it as a very strange and
wonderful occurrence, a "morbus sacer," one is rather surprised
that it and its allied disordei^ are not much more common.' It is
truly a small inconvenience if from long sitting still, or from cold.
our hands or feet get benumbed from contraction of the arteries ; as
soon as we restore the circulation all is speedily in order again, and
no damage is done. But if from any cause our brain gets into a
like state, it is no such light matter — the delicate and complicated
organ whose function is of so high a nature cannot tolerate the sus-
pension of its due nutrition and stimulation so easily as the skin can,
and its disordered actions are manifested in the grave derangement
of all the functions of the body over which it has sway. Some time
ago a child was under my care for some slight ailment, and on one
occasion I observed that its arms and hands were livid and cold.
I was told that this occurred not unfrequently without any exposure
to cold. I could not help thinking, how if the cerebral circulation
was affected in a like way ? would not serious symptoms declare
themselves ? I cannot but think that many of the peculiarities of
epilepsy depend on the peculiar arrangement of the encephalic arte-
ries. The large mass of the superior nervous centres is supplied
with blood by four trunks which are amply furnished with nerves,
and liable therefore to be influenced by them. It is clear that any
spasm of these vessels is likely to be attended with much more con-
siderable results than where, as in the case of the spinal cord, the
vessels are small and numerous, and not likely to be affected many
of them at once. The case of retinal hypersesthesia, commonly
called scrofulous ophthalmia, is worth considering with regard to
the pathology of epilepsy. The disorder is essentially one of debil-
ity, a neurosis, at least I can affirm this of some exquisite cases.
The debility gives rise to the hypereesthesia according to the general
law, and this determines the most intense spasmodic muscular con-
traction. It is true this contraction is sub-continuous, but we have
instances enough to prove that a permanent irritation acting on the
encephalic centres may give rise to intermittent phenomena. So
in many cases of epilepsy primary exhaustion sets up a state of
undue nervous excitability in the medulla oblongata and adjacent
parts which then gives rise to intermittent motor disorder.

The treatment of epilepsy and of its kindred states may be de-
signated as either empirical or rational. To the former I entertain
a decided aversion, yet would thankfully accept any proofs of the

' The divine old man of Cos clearly foresaw this. Hippocrates' Works, Syd. Soc.
Edit., vol. ii. p. S43.

EPILEPSY. 141

real virtue of remedies, which must be regarded in this light. Alisma
appears once to have done good in my hands, but probably it would
fail in most cases as it did in the next I tried it. I have no notion
of any reasonable ground on which we could expect it to be beneficial.
Cotyledo umbilicus has perhaps more claim to notice, but I have
had no success in its use. The list of such remedies is endless, and
the encouragement to experiment with them but small. Still I
think we should not wholly abandon remedies of this class, and in
many refractory cases we are sure to meet with we shall do well to
follow the example of Dr. J. W. Ogle, and test the virtues of the
galium album, and similar herbs. Considerable allowance should be
made for manifold idiosyncrasies, which are in all probability more
numerous and developed in the cerebral tissue than in any other.
Under this head we may allude to the desirable gift possessed by
some men, so much more than by others, of inspiring confidence and
hope by their mere presence and speech. It is unfortunate that ex-
perience does not tend so much as one could wish to develop this
quality.

The aim of rational treatment is first to remove exciting causes of
the disease, if any such can be detected, as worms, misplaced teeth,
masturbation, &c. Next we must seek to correct any evident faulty
state of the system, angemia, plethora, debility, syphilitic infection,
or the like. We may then proceed to combat the especial vice,
which is the " fons et origo mali," viz., the undue excitability of the
nerves or nervous centres. For this we have various sedatives of
considerable efficacy. In violent, rapidly-recurring paroxysms mor-
phia, as Dr. Sieveking has shown, will do good service. In ordinary
chronic epilepsy belladonna or henbane long and steadily continued
is preferable. They should be given in sufficient doses to produce
some decided effect. It is common with me to give gr. j extr. bellad.
ter die after having commenced with gr. J or gr. \. Henbane may
be given in gr. v to gr. x doses of the extract ter die. These sedatives
may often be advantageously combined with zinc, tannin, or nitrate
of silver; ol. morrh. may also be given in many cases along with the
sedative. Counter-irritation by means of an issue in the arm, a seton
in the neck, or remote blisters, should be used when there are signs
of over-active circulation in the head. The good results obtained by
V. der Kolk from the insertion of a seton in the neck, the actual
cautery, issues, and cupping are certainly very striking. In some
instances considerable improvement of the mental faculties which
had been impaired by the disorder ensued on the use of these means.
Purging may be advised in cases which are tolerant of it with the
same view. On the other hand, we shall meet with many cases
where the indication is to tone and invigorate. Here we have to
select the least irritating tonics, as tannin, zinc, nitrate of silver,
and cod-liver oil. Dr. Anstie has specially commended the latter
of late in all chronic convulsive disorders, and I am much disposed
to agree with him as to its beneficial action, at least wherever there

142 EPILEPSY.

is evidence of nervous exhaustion. He finds it, however, useful even
where the general nutrition is excellent. In states of great nervous
prostration I think strychnia is of material use, just as it is in chorea.
Determination to the head may depend upon loss of tone in the
vaso-motor nerves, or the arteries, and tonics may then be the most
effectual means of controlling the hypersemia. This is a case, how-
ever, in which much tact and judgment are requisite, especially at
first, lest the tonics prove irritants to the over-excitable brain.
Tannin, which is no mean tonic, has also the very desirable property
of constringing the bloodvessels, and on this account is very appro-
priate in a disease where there is so much tendency to dilatation of
the vessels by repeatedly-recurring congestion. I have heard on
good authority of bichloride of mercury having been employed with
the best results. The action of this drug is a mystery to me ; by
some it is ranked as an excellent tonic, and certainly it is unlike any
other mercurial that I am acquainted with. If it be regarded as a
mercurial, it would be appropriate, I think, to conditions where,
together with increased excitability of the nervous tissue, there was
also local attraction of blood, a quasi-inflammatory nisus. That
mercury properly employed has the power of annulling this morbid
attraction of blood I am convinced. Bromide of potassium is highly
spoken of by good observers as a remedy which is of great value in
diminishing the number of fits. It will keep them oif for long
periods, even for a year, but they are prone to recur when the
medicine is discontinued. The dose is gr. v ad xxx ter die.

Much importance is attached by several authorities to the arrest
of any aura that can be detected, and there seems sufficient evidence
to show that the repeated suppression of it may be curative. It
occurs, however, only in about half the total number of cases, and
when it does occur it is not by any means always in a part where
any means of averting it can be employed. Further there is I think
some ground for apprehension that it may but prevent the manifesta-
tion of the disorder for a time which will ultimately break out w^ith
increased severity. Rchroeder v. der Kolk says this is to be feared
even with our ordinary drugs, leading even to a fatal result.

One sine qud non to successful treatment is that the patient
should repose a cordial reliance on his physician, and that the latter
should gird himself to a prolonged and difficult contest. Obstinacy
on the part of the disease must be met with patient determination
not to be discouraged ; and I speak from experience when I say that
we shall sometimes achieve good success after we have often been
almost ready to despair.

The hygiene should be most carefully regulated, and everything
should be avoided which can tend to diminish strength and increase
excitability. The diet should be simple, but nutritious, cofiFee and
tea had better be forborne, or sparingly indulged in. Good malt
liquor may be allowed if it agrees, or instead, if need be, a little
■wine. Tolerably robust persons will no doubt do wisely to become,

EPILEPSY. 143

as a rule, water-drinkers. Romberg recommends to erethetic sub-
jects a milk and vegetable diet. Cold affusion in the form of a
morning douche or shower-bath will be serviceable in most cases.
As much open-air exercise should be taken as the intervals of the
fits will allow, as there is probably nothing which tends more to
diminish morbid excitability. The good effect of the exercise will
be much enhanced if it can be taken in the pursuit of some interest-
ing recreative occupation. To many patients who cannot abandon
their occupations it will of course be impossible to carry out these
latter regulations completely, but they must be encouraged to do
what they can, and reminded of the proverb, "that half a loaf is'
better than no bread." To unmarried patients strict chastity of
mind and body should be commended, to the married a sparing use
of the conjugal bed. This is of course an extremely delicate matter
to touch upon, but the effect of sexual indulgence on the nervous
system is so considerable, especially in weakly persons, that a
medical adviser can by no means leave it unnoticed. That which is
quite innocuous to a sound man may be very pernicious to one of
epileptoid tendency. In young persons of both sexes the existence
of vicious habits must be considered possible, and measures must be
taken for the detection of this wretched practice. It is one of the
most unpleasant tasks that can befall a medical attendant to have
to institute such inquiries, scouted as'the very idea is likely to be at
first by the parents ; but too much is known of the prevalence of
this vice and of its ruinous effects to allow us in doubtful cases to
ignore it. There is abundant room here for tact and discretion, and
perhaps the best way of proceeding is for the ordinary attendant to
divide the responsibility of the inquiry with another, who appears
more as a stranger, and is less likely to give offence.

The subject of puerperal convulsions has so much connection with
that of epilepsy that I cannot but allude to it here. Not that we
can regard the two disorders as identical, for there is evidence to
show that epileptic females are by no means prone to suffer from
puerperal convulsions. It is plain, however, that while they are
different there is a considerable resemblance between them, and that
any conclusion we arrive at respecting one must have a bearing on
our views regarding the other. Of true epilepsy albuminuria forms
no part, while in puerperal convulsions it is almost constant. It is
probable that the toxic state of the blood materially modifies the
condition of the nervous centres. In true epilepsy arterial spasm
plays a prominent part, in puerperal convulsions this is not the case.
The latter are in a much greater degree dependent on remote irrita-
tion than the former, whether we regard this irritation as acting
indirectly through the renal disorder it produces, or directly on the
nervous centres, or, as is most probable, in both ways. However,
regarding the two disorders as certainly very much allied, the point
to which I wish to draw attention is the following — viz., that there
exists good evidence to prove that the pathological state giving rise

144 EPILEPSY.

to puerperal convulsions may vary considerably from a highly
sthenic to an asthenic quality. Excellent authorities testify that
copious venesection is a very valuable remedy in many instances as
well as nauseating doses of tartar emetic ; while in many others it
is admitted that chloroform inhalation tranquillizes satisfactorily the
morbid excitement. Sir C. Locock says' that these convulsions
" appear sometimes to depend upon a loaded (congested ?) state of
the brain ; at other times the brain appears to be influenced by dis-
tant irritation either in the uterus or digestive organs ; and again
in some cases puerperal convulsions are induced apparently by a
peculiar irritability of the nervous system." I cannot but think that
these views are very applicable to epilepsy, and that we may aflBrm
almost the same of the one disorder as of the Other. At any rate
they must be admitted to add considerably to the probability that
the essential morbid state in epilepsy may be very different in dif-
ferent instances, and may require extremely different modes of treat-
ment.

I append here a summary of cases of epilepsy.

No. 35. — W. B., m., set. 29, had suffered two years off and on with attacks
of non-ccnvulsive epilepsy occurring every fourteen days. Has warning by
sensations in head for two or three minutes before each attack. Under in-
creasing doses of strychnia carried up to gr. jV ^^^' ^*^? the interval was pro-
longed to eighty-nine days.

No. 36. — S. H., f., at. 16, ad. with convulsive epileptic attacks; last
two intervals were fourteen and seventeen days. Catam. regular. Under
alisma plantago the interval was prolonged to thirty-four, and again to
seventy-one days, at which date she was discharged, having had no return.
Admitted again with recurrence five weeks later, same treatment pursued ;
— the first interval was thirty-three days, then she had three fits in ten days :
— -alisoia was continued and she took beside tr. ferri muriat. ttlx + tr.
opii TT^v ter die; the next interval was twenty-seven days, and then the
same treatment was continued 100 days without relapse ; she was then dis-
charged, and has not, though more than a year has passed, presented herself
again.

No. 37. — E. B., m., set. 17. Ill four years with epileptoid attacks on ad. ;
he has four to sis in the day and many at night. Digestion bad. Alisma
of no benefit. Tannin, and subsequently tannin and opium, with at first
acid, muriat. -}- acid, hydrocy. dil. and afterwards tr. arnicse was given for
eighty-four days with great advantage, so that he was free from attacks in
the day, but often had a " touch" at night. For the last six weeks he was
under my obsei'vation be did the work of a light place.

No. 38. — W. S., m., ^t. 20. Subject to fits seven years, had three fits
last week, has usually about twelve a month. His head aches much and
gets hot before the attacks, and he has sparks before his eyes. Under extr.
bellad. gr. J ter die with mist, ferri laxans he had no fits for eighteen days,
and did not attend afterwards.

No. 39. — J. N., m., aet. 22. Has had fits for eighteen months, about

^ "Cyclop, of Pi'ac. Med.," art. Puerp. Convulsions.

EPILEPSY. 145

two a week generally, but is sometimes a month without any. He took extr.
bellad. gr. |- bis die for 105 days, and had no fits all the time, only threat-
enings, in which he stated that his hands twitch and start, and his legs get
weak ; medicine omitted.

No. 40. — E. E., m., ast. 48. Has epileptic attacks at intervals of about one
month ; has had none now for ten months. Head cut deeply several years
ago by a fall from his box while driving. He was senseless for a week, and had
bleeding from the right ear. He seemed to recover from this, but in about
two months had a fit partly induced by the heat of the weather, ever since
then has been subject to the fits, which occur without warning. There is a
cicatrix on the forehead which is adherent to the bone, but not very tender.
This cicatrix was blistered, and he took tr. hyoscy. ttlxx ter die, with ol.
morrh. 5j- Under this treatment he improved very much, became less
nervous, his vision which had been misty got clearer, and no attack occurred.
He described himself at the end of sixty-seven days " as a man compared to
what he was." Subsequently, however, the attacks recurred.

No. 41. — F. B., f., set. 31. A very nervous subject, has fits occurring at
irregular intervals ; is weak and trembling. She took strychnia in doses
gradually increased from gr. ^V to g^"- i ter die, with iron and liq. opii sed.
with great advantage. Subsequently she had tannin with small doses of
morphia and argenti nitras. The frequency and severity of the fits appeared
to be controlled, and her general condition was improved.

No. 42. — A. R., m., set. 11. Ill for a year with fits, recurring at first
every two months, but every day for the last week. They last five minutes
to an hour. In the fits he bites his tongue, and struggles much. Severe
pain in left hypochoudrium after, and is very sleepy. Has lost his speech
three months. Health pretty good. Pupil of medium size. Ordered, April
23d, tr. hyoscy. tt^xv ter die and ol. morrh. ^yjer die. May 14th. Two
fits since April 23d, the last on 26th. Is much better in himself. Does
not speak above a whisper. 28th. Has regained his speech. June 11th.
Feels better than he has been for years ; no return of fits. Discharged.
He had a relapse in September, and was treated by tr. bellad. 1^5 + ferri
et quinae citrat. gr. vj tei' die with ol. morrh. ; three fits occurred from Sept.
24th to 28th, none afterwards up to Oct. 22d, when he ceased attendance.

No. 43.— J. P., m., set. 19, ad. Oct 2, 1862. Ill six months, is subject to
fits, has had nine. Last interval three weeks. Before they come on he feels
unsettled in his head for a day. In the fits he shakes, has singing in the
ears and falls down, lies unconscious ten minutes, but it is thirty before he
is fully recovered. They occur mostly of a morning. Health otherwise good.
Is growing fast. Pulse very small and feeble. He thinks that suppressed
perspiration of the feet may be the cause of his attacks, but admits that he
has practised masturbation. His forehead on various occasions has appeared
notably hot, and the circulation in the skin over-active, while the feet and
hands are apt to be cold. At one time, while they were perspiring, he felt
much better. The face and ears he describes as burning for twenty minutes
at once. He has various other symptoms indicative of nerve disorder, and
seems to be rather of a fanciful tendency. His condition is certainly not one of
plethora, but is equally remote from anaemia; the most evident abnormality
is the irregularity of the circulation, the arteries of the head being disposed to
admit an undue supply of blood. Atropine and belladonna did not appear
to be beneficial, his head was cooler and quieter while taking extr, hyoscy.
10

146 EPILEPSY.

gr. V ter die. An issue in the arm was of no avail, besides much other
treatment, including tannin, argenti nitras, and pot. iod.

No. 44. — F. L. set. 11, f., ad. Nov. 16th. Had fits when three years old,
and was ill a long time, lost all his faculties for a month, and was paralyzed
on one side. Recovered and remained well for seven years and free from
fits, but since then he has had them at intervals of about six weeks. Two
fits occurred in the last week. Becomes quite unconscious in the fits, which
always occur during sleep; the following morning he is dull, stupid, has
headache, and is very irritable. Head rather hot, has some pain in it now.
Large face, red lips, pulse regular, quiet. Some warning is afi'orded of an
approaching fit by his being tiresome and irritable the previous day. He
remained under observation till Feb. 22d, when he had had no fit for three
weeks, previously they occurred about once a fortnight. Tonics and blisters
to the neck did not seem of benefit, zinc gave more promise of good.

No. 45.— M. S., set. 20, f., ad. Nov. 15 ; ill two days. Had a fit at first,
in which she bit her tongue ; since then has had nine or ten fits, but not
" insensible ones," left side only affected by the convulsions. Some frontal
pain, better when recumbent. Has felt giddy lately, but not weak. Has
passed ascarides. Cat. regular. B. open Nov. 18th. The shaking fits in
left side continue, and she has temporary loss of power over the arm, leg
not affected. The fits occur very frequently, more so at night. In four
days the fits had ceased, and Dec. 20th she was discharged, well. The im-
provement commenced as soon as she was ordered ferri et quin. citr. -\- tr.
nucis vom. A blister applied at first to the neck was of no benefit.

No. 46. — J. K., set. 41, m., ad. Sept. 6th. Suffers from nervous debility,
which brings on fits ; has been getting worse last three months. For last
ten years has not debauched. Looks ill, and his face sunken. Skin cool.
Pulse weak. Takes food well. B. regular. Has much pain all over his
head as if his brain was on fire. Is subject to attacks of headache, lasting
three to four hours, in which he vomits much yellow bile. In evenings, he
feels the blood flowing up to his head for two hours, and has dreadful sen-
sations 3 at other times it seems as if his life was departing he is so chilly.
Every other day he experiences nervous tremblings and low spirits, with
fearful apprehensions, which come on worst in the evening. The fits occur
at various intervals once a month or oftener; he afSrms that he is more
liable to be attacked at the changes of the moon. The fits come on, he says,
with palpitation and fluttering of the heart; the blood then flows to the
head, and when it has reached a certain part at the back he becomes uncon-
scious. This man was highly hypersesthetic, and a very unpromising sub-
ject for treatment. Full doses of tonics did not seem to benefit him, but
assafoetida gr. x otis horis did considerable good; "a world of good," as he
stated. He remained under treatment till Feb. 27th, and had no fits during
the last two months. I regret that I did not give him ol. morrh.

No. 47. — W. A., set. 53, m., ad. Ill two months. Was at first confined
to bed ; was quite insensible at times, and used to talk wildly ; had pain in
head ; no paralysis ; no fit ; since then he has recovered a good deal, but is
attacked many (fourteen or fifteen) times a day with loss of speech, weakness
of limbs, some giddiness. This affection soon passes off, leaving him quite
well. While in the consulting-room he had an attack during which he was
unable to speak plainly as before. He compares the attacks to a sudden
cloud passing over the sun. When they occur while he is walking he has
to stop. Pulse weak, languid, 86. Pupils nearly equal, mobile. Syphilis

EPILEPSY. 147

denied ; some stricture. No worms passed, not even after a dose of male
fern. On one occasion I dilated the pupils with belladonna, and examined
the fundus of the eye while an attack occurred, but I could perceive no
manifest pallor of the red field. Opium in gr. h doses lis die seemed to
check the attacks for a while; afterwards he benefited with strychnia and
tannin. His health became better ; he had not to stand still when the fits
came on, and they were less severe, but as frequent. This was a well marked
instance of "le petit mal."

No. 48. — M. A. S., set. 12, f., ad. Jan. 21. Ill one year. Has something
like fits in which she is unconscious, and appears as if strangulated ; her
eyes water. They occur about once a week. Has often violent pains in
eyes and head; sight dim. When six years old passed round worms, but a
dose of male fern now brought none away. With tannin she benefited ma-
terially, but ceased attendance too soon. Belladonna in small doses, and a
seton in the neck, did not seem beneficial.

No. 49. — H. W., set. 64, m., ad. June 6th. Subject to epilepsy eleven
years from an injury to his head, on account of which he was discharged
from the police. No attack for two years till eight days ago. Has numb-
ness in right side of face, right arm and hand, and pain down back of right
leg. Feels giddy and trembling, and shaky if excited. No pain in head.
If he gets up suddenly he cannot see for a time, and everything swims before
his eyes. Is a painter now; has dirty teeth, no blue line. Urine quite
clear, and normal-looking, not albuminous, sp. gr. 1018. With ammonia,
valerian, tr. hyoscy. and tr. nucis vom. and 5j doses of ol. morrh. ter die
he recovered from the above symptoms, which were probably sequelae of the
attack, and felt almost as well as ever he did in his life. ■

No. 50. — W. H., set. 5, m., ad. Sept. 21st. Ill since one year old with
fits which occur at intervals of one to nine months, several often occur to-
gether. In the fits he cannot get his breath, is black in the face, and un-
conscious ; screams much. After fits, has fever for several days, and is ill
for three or four weeks. Last fit three weeks ago. Pulse not weak ; skin
hottish. Another fit occurred Oct. 14th. He took tr. ferri mur. with much
benefit, and afterwards liq. pot. arsen. and ol. morrh. when some eczema
appeared, and improved still further.

No. 51. — E. P., aet. 9, f., ad. Oct. 8th. Ill three months with fainting
fits, but has struggling fits last fourteen days. She struggles and screams ;
complains that her head is coming ofl^; loses consciousness for three-quarters
of an hour. The fits begin with drowsiness; she lies down and goes to
sleep, in about ten minutes the fit comes on. Had two fits yesterday in
the afternoon. Before the fits commenced she used to have pains in the
abdomen, and in the side like cramp ; these have ceased. Is restless at
night, talking and tossing about. Head not hot; urine rather pale; no
appetite for meat. Is weakly. Has scrofulous disease of one foot; not
anaemic; tongue clean. Nov. 6th. Appears as if her intellect was affected;
is unaccountably lively after pain in head, which comes on generally about
6 P. M. The forehead is very hot then. Before this she had materially
improved. She was treated till Dec. 22d with ferri et quin. citras, and im-
proved very much, so that she was not like the same child. The fits had
ceased for some time before she quitted the hospital.

No. 52.— W. S., set. 49, m., ad. Feb. 24th. Ill ten weeks with catarrh
and fits. He was suddenly seized with unconsciousness while at his work
(bootmaking), and remained so for half an hour. Did not struggle, or bite

148 EPILEPSY.

his tongue ; foamed at the mouth. During the fit his mouth was drawn to
one side. Has only had two fits; the first came on nine, the last three
weeks ago. He had one fit previously seventeen or eighteen years ago.
When he talks his mouth is drawn to one side, and his tongue to the oppo-
site. He was ordered carbonate of iron and tr. nucis vom. with bark, and
subsequently ammonia. During five weeks that he remained under observa-
tion he had no return of the fit, and became much less nervous. He had
one bout of sharp abdominal pain (neuralgia).

No. 53. — M. B., set. 19, f. Ill four or five months. After having had
a sore on her finger became low and weak, and then fits came on. Last
week she had fits every day but one ; she is much convulsed in them j they
continue as a succession three-quarters of an hour. Screams in the fits, has
sopor after. Complains of a lump in throat, and is very nervous. Skin
cool; pulse natural; catam. regular; bowels regular; head very hot.
During the six months that she remained under my care this heat of head
was a constant and remarkable symptom ; it was attended with very marked
activity of the circulation in the head, contrasting strongly with an opposite
condition in the hands and feet. The forehead presented a uniform red
flush, scarcely obliterated for an instant by pressure, while in the hands the
blood after being pressed out returned again very tardily. At times she
had much "swimming in the head, feeling as if she should fall when she
got up," and much headache in forehead and temples. The distress of the
head was relieved by leeches to the temples, blisters to the neck, ice locally
applied, and dry cupping. She was better during cold frosty weather. The
fits occurred at various times of the day, not at night. Her speech was lost
on some occasions for two hours. Debility was marked. Except that she
gained strength, and that the fits were not so frequent or so strong as they
were at first, not much was accomplished. She took quinine, iron, strychnia
with some advantage, large doses of assafoetida seemed also beneficial, and
small doses of morphia and henbane. Hydrocyanic acid was of no avail.
This case was certainly not mere hysteria; the state of the circulation in
the head was distinctly abnormal, and assuming the intracranial to be simi-
lar it would account for most of the symptoms. There was no real plethora,
the primary and essential defect was loss of tone in the cranial vessels and
nerves, a permanent sympathetic paresis.

No. 54. — A. W., aet. 32, f., ad. July 6th. HI five weeks, has had one fit
each Friday. In each fit the two inner fingers begin pinching and shooting,
and twitch ; the pricking, &c., extends up the right arm to the side of the
head, " the arm works," and then she loses all consciousness ; she falls down,
her face is drawn to one side, she is convulsed and bites her tongue (seen).
The feeling in the head sometimes occurs without a fit. Is always drowsy.
Does not sleep well. Suckling five months. Has had eight children, some
born dead, only two living. None of them have had eruption. Not anaemic.
Very nervous and excitable. Dyspepsia lately. Bowels irregular, open
much at times. She only remained seventeen days under observation in
which time no improvement took place. She took iron, ammonia, and hen-
bane.

No. 55. — E. F., f., aet. 15 months, seen April 25th. Ill nine months,
first had severe diarrhoea which was followed by slight convulsions, and then
by bad fits, which have continued ever since, occurring generally every week.
Sometimes the fits occur on a Saturday morning, at 8 A. M. for several weeks
together, though there may be fits also in the intervening days. The most

EPILEPSY. 149

remarkable phenomena as I see her at present are the great collapse of the
ribs in inspiration, the prolonged groaning character of the inspiration, a
certain amount of cough and attempt at expectoration. She swallows well.
Consciousness is impaired since her illness, but not lost; there is no evident
paralysis. Urine appears natural, but very scanty. Pupils of medium size.
No fit now for eight days, the fits last about five minutes, but it is half an
hour sometimes before she is quite restored. She has been breathing as at
present for ten or eleven days. Crams very much her fingers into her mouth,
no trace of teeth, is fed from a bottle. Death occurred a few days after ; a
careful autopsy discovered nothing morbid in the brain, nor in the organs of
the chest and abdomen.

No. 56. — S. S., 83t. 45, m., ad. December 22d. Ill about four weeks,
since a fall from a height of about eight feet. Is of stout, rather short make
and sanguineous aspect. He had been cupped at the back of the neck ad
oviij, had a seton put in the left arm, tartar emetic ointment applied to the
neck, and had been purged without benefit. He suffered from attacks of
the following kind occurring five or six times a day. He begins to wink,
and then both eyes become drawn quite under the lids towards the right,
one inwards and the other outwards ; he then loses consciousness for four or
five minutes, and falls down, does not scream, but moans as if choked. I
witnessed the attacks more than once; they were perfectly involuntary, not
attended by much flushing of head. He feels tremulous and nervous ; does
not sleep well ; has a trembling in the head when he lies down. Not an in-
temperate man. No syphilis. Bowels open. Pulse of good force, skin warm.
"Was similarly affected two years ago, and got well after six months. He
remained under observation till Feb. 20th, when he ceased to attend, having
had only slight attacks in the previous fifteen days, and having been nearly
free during several former weeks. Assafoetida in gr. x doses '2dis Jioris, and
iron and quinine seemed to be the efficient means in subduing the neurosis.

No. 57. — A., aet. 39, m., has had a touch of African fever formerly. Ad.
April 2d. Ill three or four months, on and off. At first he lost his speech,
it is now impaired. His arms and legs feel weak at various times, chiefly
on exertion. Has a dull pain across the forehead, not constant, and not
worse when lying down. Head rather warm ; no tenderness in cranium or
spine ; intellect seems obscured, memory impaired ; skin cool, pulse weak,
pupils sluggish, left larger than right. Subsequently he had trembling of
the right arm and leg. Two blisters to the neck. Pot. iod. et hydr. bichl.
produced improvement; he ceased attendance, having, as he afterwards stated
got quite well. He was readmitted Feb. 23d of the following year, having
then been ill a week. His condition was sufficiently obscure, he appeared to
be in a state of general excitement and fussiness. His knees and right arm
tremble. Sometimes he falls down, sometimes loses consciousness. He is
pallid, free from fever, head rather hot, urine not albuminous. I gave him
ammonia and arsenic with which he improved a good deal, his right arm became
steady, his speech improved, no loss of consciousness occurred, but he had
on two occasions some appearance of rheumatism in the right knee. Just
after this in the night at 10 P. M. he suddenly lost his speech, and remained
speechless till his admission into the ward March 31st (two days later). The
day after he had a fit, consisting of convulsive movements of all the body,
but chiefly of the right side, with rigidity of the flexors of the arm and ex-
tensors of the knee. April 5th. There is complete paralysis of motion and
sensation in the right arm and leg, which are relaxed. Mouth is drawn to
the left. Reflex movements could be excited in the paralyzed leg. The

150 EPILEPSY.

fits above mentioned recurred frequently during his stay in the hospital,
the intellect remaining clear. They lasted two or three minutes, several
occurring one after the other ; they were not succeeded by coma ; he was
able to recognize his children immediately after them. No fits occurred
for about twenty-four hours before death, which took place April 10 ; but he
became very weak, unable to swallow, and gradually sank, his intellect re-
maining clear to the last. His evacuations were all passed under him. At
the P. M. the cerebral veins and sinuses were found full of dark blood, the
smaller veins were filled, but the gray matter was not dark, nor the minute
vessels injected. Considerable subarachnoid effusion existed, and there were
some patches of opacity over both hemispheres. The substance of the brain
was firm and consistent, the white matter congested. In each lateral ven-
tricle there were 5vj of serous fluid, and the vessels on the walls were con-
gested. Nothing morbid at all was found in the brain or cerebellum, though
they were very carefully examined for two hours; nor was there anything
morbid in the spinal cord. Microscopic examination detected nothing in
the brain. The thoracic and abdominal viscera were fairly healthy.

No. 58.— E. C, f , set. 28, mar., no children, ad. March 28th, 1861. Has
been ailing since she had inflammation of lungs and liver three and a quarter
years ago. Three months ago was first attacked with giddiness, and just
three weeks after an epileptic fit occurred. After this (the first) they
returned at the rate of four or five a day, and now occur three or four times
a week. When the attack comes on she turns pale and giddy, feels as if a
blow was given her on the head, falls down, loses consciousness, and becomes
very sick five or ten minutes after. She has constant giddiness, is very
anaemic. No tenderness about head. No worms. P. 132. Catam. regular,
but excessive. Her health is better during the summer. Her mother may
have had fits, but a brother and a sister are quite free. Pupils equal. In
January, 1863, she stated that her head always felt hot, and was benefited by
cold applications ; when she becomes giddy her head is dreadfully hot. The
recumbent posture relieves her head generally, it aches less; when erect it
feels weary as if she needed to rest it against something. She feels weak
and weary, and looks languid. March, 1864. During the last five months she
has become the subject of very marked proptosis, the globes are not nearly
covei'ed by the lids, they feel tense, and (especially the right) are notably
injected; the lids are also very red. The vision is pretty perfect; she can read
for a short time, but afterwards the letters become confused. There is great
fulness and bulging of the upper eyelids, and great pain in, and above and
behind the globes. This pain is much aggravated at night, and destroys her
sleep. There is also very forcible pulsation of both carotids, when one of
them is compressed the pain in the eye is somewhat relieved. No thyroid
enlargement. No palpitation. Ice applied to the eye and to the neck gives
more relief than anything else, but it is only temporary ; she goes to sleep,
but is soon aroused by the pain. The radial pulse is very weak and rapid,
varies (sitting) from 120 to 140. The pupils are very small. The fits
have become much less frecjuent. In the summer of 1862 she had a period
of 110 days with only one slight attack, and in 1863 she remained exempt
from June 16th to December 23d (189 days). Since then she has had two
or three attacks. The remedies which have done most good have been tan-
nin gr. X + extr. belladon. gr. j in pil. ij ter die, and sulphate of zinc +
extr. hyoscyam. gradually increased up to 18 grains of the former and 21 of
the latter daily. An issue was made in the left arm in 1861, and has been
kept open most of the time since. Large doses of morphia have been givea

EPILEPSY. 151

to procure sleep at uiglit lately and with good result, but quin. disulph. gr.
XX h. s. was even more efficient for some days. The urine is sometimes
pale and clear, sometimes deposits lithates j it is not albuminous, deposits no
casts.*

No. 59. — H. H., m., get. 38, ad. Oct. 5th. Had a fit yesterday evening
at 11 P. M., had none since his first, five years before. He went into the fit
with a loud' cry, fell down, and bit his tongue. Does not know how long he
was in the fit, but was told by his friends that he had another at 4 A. M.
this morning. The attacks occur during sleep, without any previous intima-
tion. Not at all anEemie. Is a teetotaller. No worms. Syphilis denied.
Does not suffer from pain in head. Pulse steady. No epilepsy in his family.
Is out for many hours cab-driving. He took pot. iod. + ammon. carb. with
benefit, but attended only about a month.

Among the above 25 cases there are 16 males and 9 females, and
among sixteen other cases I have notes of, there are 7 males and 9
females. In the total number, therefore, the males are to the females
in the proportion of 23 to 18. The oldest patient was a male, set.
64, the youngest a female set. 15 months. There are 10 under the
age of 20 years, and only five above that of 40. The attacks were
non-convulsive in three instances ; No. 47 was a marked example of
" le petit mal." Injuries to the head were the assigned cause of the
fits in Nos. 40 and 49. In almost all the remaining cases the cause
was quite obscure. General hypergesthesia and nervousness "was
marked in Nos. 41, 43, 46, 53, and 54, but in quite as many or more
instances there was no trace of it. The fits were few and far be-
tween in Nos. 49, 52, and 59. There were other indications of ner-
vous disorder in Nos. 39, 40, 42, 43, 46, 51, 52, 57, 58, Hyperaemia
of the head was a notable symptom in Nos. 38, 43, 53, 58. Debility
was evident in Nos. 41, 43, 46, 51, 53, 54, 55, 58. There were
premonitory symptoms in Nos. 35, 38, 43, 44, 51, 54. In 54 there
was a regular aura commencing in the hand, in the other cases there
were various sensations in the head. Pain in the head was com-
plained of to a notable extent in Nos, 46, 51, Giddiness was a
marked symptom in Nos. 45, 49, 53, 58. In 52 there -^as some
amount of facial paralysis after the fit. In Nos, 35 and 41 strychnia
appeared to have a good effect. In 53 and 56 large doses of assa-
foetida appeared useful. In No. 36 alisma plantago was perhaps
curative, but in 37 it quite failed. In Nos, 38, 39, 40, 42, 58 bella-
donna or henbane seemed decidedly beneficial, though as they were
mostly given with other drugs it is difficult to tell how much of the
result was due to their action alone. The remedies with which
they were usually associated were zinc, tannin, and ol. morrh. In
Nos, 45, 51, 52, 5Q tonic treatment, ammonia, iron, and quinine
seemed to be really curative. The nocturnal restlessness and quasi

' The sequel of this case has been very sad, but instructive. After the prop-
tosis and congestion of the oi'bital tissues and lids had existed nearly six months the
pain became greatly exaggerated, the conjunctiva in both eyes greatly chemosed with
fibrinous exudation, and effusion of lymph took place into both anterior chambers.
Prolonged hypergemia has thus issued in destructive inflammation.

152 EPILEPSY.

delirium, and the previous neuralgia incline me to tliink that No. 51
was au fond a case of malarioid remittent. No. 59 is a case of
great interest. The patient is a calm, sensible, uncomplaining
sufferer, tractable and reliable, and regular in her attendance. The
improvement in her state has been so marked that I am hopeful she
will ultimately be quite restored. The recent development of prop-
tosis with great vascular congestion in and around the globes and
strongly-marked pulsation of the carotids is highly suggestive, espe-
cially when the absence of thyroid enlargement is taken into account.
It is difficult not to regard the proptosis, &c. as a part of the origi-
nal nerve disorder, a variation probably of its seat. The head had
previously been very hot, when giddiness came on, indicating that
an increased flow of blood to some part of the encephalon ensued at
such times. Latterly the branches of the ophthalmic artery seem
to have been unduly relaxed and to have given rise to the orbital
hypersemia. The carotids are in the same state. The fact that
there is no thyroid enlargement seems to prove that the smaller
arterial ramifications are the main controllers of blood-supply. As
long as they retain their due tone and consequent calibre no exces-
sive flow of blood to a part will ensue, though the main trunks may
be throbbing violently for lack of tonicity in their coats, or from
paresis of their regulating nerves. When, however, the small arteries,
and ultimate ramifications of the sympathetic are thus affected the
tissues which they supply have their vital actions increased, and we
then get various phenomena according to the normal function, origi-
nal excitability, and tendency of the organs concerned. It is very
curious thus to find an excess of vital manifestations essentially de-
pending upon a failure of vital power (vis nervosa). It is most
probable I think that in the earlier period of this case increased
blood-flow took place towards the medulla oblongata and mesocephale.
It is very evident how important it must be to distinguish cases where
the cerebral excitability is primary, and where the hypersemia if any
occur is consequent on this excitability, and those where as in the
above instance the pathological order is reversed.

In those instances where long intervals of apparently perfect
health intervene between the fits there does not seem to be any indi-
cation for the administration of drugs. The diet and mode of life
should be however duly regulated, the object kept in view being to
increase power and diminish excitability.

In the two fatal cases which occurred the autopsy manifested no
cause for the disorder. The general conclusion which I am led to
adopt from the above review of my cases is that epilepsy in its
nature is a disorder of the nervous centres quite analogous to neu-
ralgia and hypersesthesia of the nerves. Some cases approximate
to the former, but the majority to the latter condition, and in some
the morbid action is maintained and aggravated by hypersemia,
either depending on arterial relaxation, or on local attraction of
blood. The disease which it most resembles is, I think, scrofulous
ophthalmia.

HEADACHE. .153

CHAPTER XIV.

HEADACHE.

Headache is a symptom present in so many and different condi-
tions that it has no claim to be considered a distinct disease. The
article upon the subject in Dr. Copland's Dictionary treats of the
various kinds in a very exhaustive manner. I shall only enumerate
the various kinds of inorganic headache that are met with, and give
some illustrations of them. One of the commonest kinds is that
•which coexists with prostration of nervous power, in which I conceive
the state of the brain much resembles that of a nerve suffering from
neuralgia of debility. A second is hypersesthetic headache, where,
along with more or less debility, there is considerable excitement and
hyperacute sensibility to all impressions. The two forms are
certainly distinct, though transitional instances are more frequent
than typical. The means which relieve the former are apt to
aggravate marked cases of the latter. A third form of headache is
the result of active hypersemia, and is characterized by fulness of
the vessels, heat of head, by being aggravated (this is not invariable)
by the recumbent posture, and by the relief afforded by cold applica-
tions, purgation, and depletion. A fourth form is sympathetic,
depending on disorder of the stomach or of some other organ. Dr.
Sieveking describes a haemorrhoidal form of headache, sudden,
violent, and vertiginous, attended with impaired vision and irrita-
bility of temper, and probably dependent on rectal irritation, (V.
3Ied. Times and G-az., Aug. 12, 26, 1854.) In all these I consider
the encephalon itself to be directly affected. In hemicrania and
other forms of neuralgic headache the nerves of the scalp suffer.
In rheumatic headache the same occurs in some instances, in others
the nerves of the dura mater are implicated in the morbid action.
Gouty headache may present various grades of irritative or inflam-
matory phenomena corresponding closely with the neuralgic or
inflammatory results of the action of the materies morbi in other
parts. In many cases there will be indications of the existence of
the gouty diathesis, but it is very important to be aware that, as
Dr. Copland states, it may be the first manifestation of the disorder.
Trousseau relates an interesting example of hemicrania replaced by
gout, and states that the articular and the neuralgic affection often
alternate in the same individual, and that the latter may be the
sole manifestation of the diathesis in the offspring of gouty parents.
Rheumatic and neuralgic headaches are often very difficult to
distinguish except by testing them with remedies. Pot. iodidum or

154 HEADACHE.

guaiacum is usually curative of the one as tonics are of the other.
The urine is more often lateritious in the rheumatic than the
neuralgic disorder, and there is less debility. In gouty affections
we shall generally find a deficiency of uric acid in the urine if the
total amount passed in twenty-four hours be estimated. Syphilis
not unfrequently occasions headache, or rather pain in the head, of
varying degrees of severity, often much resembling the results of
rheumatism. It is generally amenable to full doses of iodide, but
may require mercury.

No. 60.— Mrs. F. S., set. 38 (?), seen July 27th, 1861. Has been much
in India, but never had fever or ague. Has no mental distress. Looks
thin, wan, and poorly ; forehead large, peculiar expression of countenance
giving one the idea of impending insanity. Has suffered for three or four
years with headache paroxysmal, but very severe indeed while it lasts, which
is from twelve to forty-eight hours. It returns once or twice a week, is
relieved by nothing but chloroform (inhaled) and morphia; the latter acts
slowly, she takes 2 grains without any sopor ensuing; chloroform relieves
immediately. At the time when the headache is present is almost distracted
by violent throbbing at the vertex, which is somewhat relieved by firm pres-
sure. Head then seems hot to her, it is cool now. She can lay her head
down without increasing the pain. Superficial veins of neck very large.
Does not sleep well always, has sometimes restless nights preceding the
attacks of headache. Some decayed teeth, but they cauise no notable un-
easiness. No worms. Urine palish, free, acid, sp. gr. 1011. P. soft, weak.
Skin cool. She was ordered strychnia with citrate of iron and quinine ter
die, and to take supper with malt liquor at night. In about six or seven
weeks she had benefited very much, slept better, but still had to take a cup
of cocoa in the course of the night. At this time she had hemicrania of the
right side, which she said was quite different from the head-attacks she had
had previously. The veins of the neck did not appear full now. A month
later she suffered pain extending down the right leg from the hip to the
toes, apparently in the centre of the limb, quieted by cold, and induced by
heat. Nov. 8th'. Pain has shifted from leg to arm, the right shoulder and
arm are stiff and painful each morning, the pain runs down the arm. " It
is a misery to turn or move in bed." During the day the pain subsides.
Headaches less and less. This arm-pain was soon cured by chloroform lini-
ment and the Turkish bath. Jan. 6th, 1862. The headache has recurred
the last three weeks with hysterical symptoms and depression. It is most
probable that the neuralgia in this case was of malarious origin, although
there was no history of fever. The tonic treatment plainly averted to a
great extent its recurrence. The disorder exhibited the usual shifting
tendency of neuroses, its hemicranial manifestation, and the quasi-rheumatic
affection of the limbs was less-distressing than the original in which the brain
itself seemed to suffer.

No. 61. — Mrs. W., set. 24, has been much in India during her early life,
and has been under my care previously for neuralgia of the side, and for ery-
thematous flushing of the face. Has had brow-ague thi-ee or four times.
Pregnant about seven weeks. She has been suffering severely for three or
four days with pain in the head chiefly on the left side, and such great irrita-
bility that mere rustling of paper distresses her. Her face looks somewhat
flushed and oppressed. P. rather excited. Appetite tolerable. T. clean.

HEADACHE. 155

Urine pale. E. open. The headache remits during the day, but comes oa
severely about 5 or 6 P.M. During the night she is markedly feverish, and
wakes often from short dozing sleep. With quinine at first, and quinine and
iron afterwards, the headache was reduced to a minimum in about a week.

No 62.— A. P., ^t. 20, f., ad. April 29th. Ill five or six months.
Suffers with head ; " comes over with such sensations that she quite goes out
of her mind." Head cool ; it feels giddy and confused. Left hand and arm
get numb at times and her speech fails. Cat. regular. Much palpitation.
Functions in order. Ammonia, iron and calumba were highly beneficial.

No. 63. — A. H., set. 50, f., ad. Nov. 16th. Ill three months, head feels
light, and sore and weak, occasionally has sharp darting pains in it, which
make her stagger. Can't sleep at night for tenderness of head. Some
deafness. With iron, calumba, and cod-liver oil, and henbane at night, all
her symptoms very much improved.

No. 64.— H. P., ^t. 10, m., ad. Feb. 6th. Never well from birth. Has
frontal headache almost every day, eyes feel as if on fire. Suffers with
violent attacks of sickness, retches much. " Eyes work continually." Has
occasionally swelling of the dorsum of the left foot. Ague has occurred in
the village where he lives. Is languid. With citrate of iron and quinine
+ tr. nucis vom. he got a great deal better; after an accidental relapse (per-
haps from some wrong medicine being given) pot. iod. was added to the tonic
and ol. morrh. given, which he continued till June 10th, when he was fairly
well except being still rather weak. In the first of these four cases there was
extreme neuralgic suffering, in the second there was much of this and also of
hyperaesthesia, in the third the brain seems to have been in a condition re-
sembling that of " anaesthesia dolorosa" in a nerve ; the last affords an exam-
ple of cerebral debility and neuralgia, with associated stomach disturbance.
That mere exhaustion of the brain will cause gastric disorder I am satisfied.
A lady, set. 70, of very feeble power told me that she had always been very
liable to sick headache, she remembered perfectly that going about sight-
seeing used constantly to induce an attack of sick headache attended with
nausea and retching.

No. 65. — M. A. B., f., set. 39, ad. Nov. 8d. Ill a week, has been suck-
ling eight months. Has a peculiar pain in the head which she cannot
describe ; is very irritable, and at times says she is quite violent. Is afraid
to be trusted by herself. Does not sleep at night. Memory very failing,
can't remember from one day to the next. Can't endure the slightest noise.
Pusle 100, small. Pupils of medium size. She benefited very much with
ammon. carb. gr. v +^th. chlor. n^^x -j-liq- opii sed. Tt\^xx ter die. In
a week she slept better, appetite was better, the pulse had fallen to 72, and
was of good volume. In this case there was a marked blending of the symp-
toms of cerebral exhaustion with those of hypersesthesia and excitement;
pretty full doses of sedatives were certainly beneficial combined with
stimulants, but did not act. so well alone, as they were given for the first
three days.

No: 66. — C. W., set. 44, ad. Jan. 12th. Has suffered from headaches
almost constantly for the last two years. Is of stoutish make, not anaemic.
States that she suffers from pain in the chest, and in the arms and legs,
which is much worse at night; can't lie down in bed, feels suffocated and
is obliged immediately to get out. Has frequently frightful dreams. At
times feels almost induced to commit suicide. Bowels very confined, unless
she takes medicine. Pulse 108. Has much pain at mid-sternum extending
up into throat with sensation of choking. March 12th. Is iu a state of

156 HEADACHE.

the most extreme hyperaestbesia, crying and agitated, can't sleep, walks
about the room all night long. No appetite. Urine scanty and thick.
Says her illness commenced with rheumatic pains in left arm extending up
to shoulder, these have been gradually leaving her, and the arm, which was
very weak so that she could not hold a teacup, has become much stronger.
Her head and nerves became aflFected three or four days after the rheuma-
tism came on. June 4th. She was discharged very much improved, had
been mending steadily since March 16th. She was treated at first with
aperients and antispasmodics and with material benefit, but after the relapse
March 12th she took calomel and colchicum at night, daily ad vices iv., then
aJt. noct. for a week, then twice a week for more than a month. Black
draught was given almost daily for nearly the same time. The hyperaestbe-
sia and nervous distress in this case were very great, quite verging on in-
sanity, and proving that the cei-ebrum was essentially involved in the morbid
action. There was no indication of gout. 1 doubt whether mere purging
was the efficient remedy as she had taken aperients pretty freely before her
relapse, including at last nightly doses of ol. Crotonis n^ i.

No. 67. — T. A., set. 26, m., ad. May 2d. Ill four years, always weakly.
Is very nervous, and has pains in his head. Complains that strange almost
uncontrollable thoughts come into his mind. Anything that excites him in
the day makes him wake up and call out at night. Feels very weak. Bow-
els costive. Quinine, iron, strychnia, and opium were of very great service
to him. He remained under treatment over three months.

No. 68. — J. D., set. 7, m,, ad. Dec. 4th. Ill twelve months. Is very
violent and excited at times, tries to get out of the window, throws things
about, is restless at night and has delusions. Takes food ravenously, is
never satisfied. Complains at times of pain in head and chest. Is much
worse last three months, m^ich worse at the change of the moon. Skin cool.
Pulse feeble. Tongue clean. Bowels open. He took at first ferri et quin.
citrat. gr. vj -f pot. iod. gr. iij ter die, and a small opiate at night for
three weeks, subsequently tr. nucis vomicae was substituted for the pot. iod.
He ceased attendance March 2d, but I heard of him on April 18th that he
continued much better, more submissive and controllable, and attended
school both Sunday and weekday, which he had not been able to do previ-
ously. In all these three cases there was very marked cerebral hyperassthe-
sia and excitement with more or less pain in the head. In the first the
condition was of asthenic character, purgatives were of marked benefit and
stimulants unavailing. In the two latter tonics and sedatives were of
marked remedial efficacy. It is most probable in the first case that the dis-
order was induced by some morbid condition of the " primae viae," while in
the others it seems to have been based chiefly on debility. It may depend
very much whether the morbid action affect the nerve-cells or the white
fibres which result is produced, viz., mental excitement or pain. Pain we
know is caused by an enfeebled condition of nqrves, and delirium we also
know results from cerebral exhaustion. The phenomena vary with the
tissue affected.

No. 69. — E. A., f., ast. 32, ad. Aug. 30th. Ill fourteen days, ailing a
long while. Suffers with dreadful headache and sickness; the headache
extends from the front to the back, is constant, and is not affected by position.
Left side of face, and tongue, and arm, and hand are numb; the numbness
begins in the tips of the fingers, and extends upwards to the face, lips, and
tongue. At these times her speech becomes thick, and continues so for an

VERTIGO. 157

hour at times. The attacks of mimbness occurred two or three times a week
or oftener. Has no appetite, food causes pain, and is vomited directly. Has
a sensation of tremor at stomach. Bowels open. Tongue whity. Skin
cool. Pulse good. Feels very weak. Head a little hot. For the first three
days she had strychnia gr. 2V '<?'" <^<'e> ^^^ without any benefit. A blister
was then applied to the epigastrium, and she took acid, hydrocy. dil. rriv
+ mist. pot. citrat. Sj (efi'erv.) tei' die. This soon stopped the sickness,
and then tannin pills were given bis die in addition. By Oct. 16th she was
very much better, the stomach was right ; she had had two returns of the
numbness but much less than it used to be. In this case the gastric disorder
was primary and the head-pain and cerebral paresis were produced as I
believe by an inhibitory action exerted through the sensory nerves of the
stomach on the higher nervous centres. Various morbid conditions of the
primx vise will give rise in predisposed persons to headache. Dr. Prout^
describes excessive acidity of the caecum as producing in certain persons severe
frontal headache, attended with complete intolerance of light and sounds and
a state of mind bordering on delirium. After a longer or shorter duration
the pain ceases, sometimes quite suddenly; and this sudden termination
Prout connects with a relaxation of a spasm of the bile-duct, and a flow of
bile into the intestines, partly from a description of the sensations which
others have invariably experienced, and partly from his personal experience
of the disorder.

CHAPTER Xy.

VERTIGO.

This symptom, for it scarcely attains the rank of an independent
disorder, is of suflGcient interest and importance to require a brief
notice. Its relation to epilepsy is recognized in the term epileptic
vertigo, which is applied to the lesser form of the malady. It is
eminently a dynamical disorder, as though often occasioned by toxic
agents its most exquisite forms are certainly generated by influences
of a totally different kind. It occurs ,as Dr. Copland justly observes
in predisposed persons both from excess and from deficiency of blood
supply to the brain. It is also produced by various causes of cere-
bral debility without any notable variation of the circulation. Any
sudden diminution of the pressure exerted upon the encephalon by
the blood circulating through it and by the subarachnoid liquid
seems to induce giddiness. As regards the blood the effect of im-
pending syncope is familiar. As regards the subarachnoid fluid we
may cite Cruveilhier's experiment. He states that if the sheath of
the dura mater in a dog is punctured between the atlas and the
occipital bone, and the spinal fluid allowed to escape, the animal
reels about like a drunken man, and lies down for hours in a state

' "Stomach and Renal Dis.," p. 81.

158 VERTIGO.

of stupor. The day following he is quite recovered. Probably the
giddiness which we experience on rising quickly, after having been
stooping down for some time, depends in great measure on the reflux
of the subarachnoid fluid towards the spinal cavity, which while the
the head was depressed gravitated towards the cranial. It is worth
observing that the giddiness does not occur while the pressure is
increasing, but when it ceases. The vertigo which is felt after
rapidly turning round, or in states of nervous debility from any
quick movement of the head, cannot I think be owing to any change
in the circulation or in the external pressure, but to a dynamic
derangement of the cerebral structure. It is induced the more
readily in proportion to the weakness of the nerve-power. Its
nature is somewhat elucidated by the fact that the same feeling is
experienced on looking down from a great height, when we have
not a distinct perception of the objects below, or when we look at a
rapidly-flowing stream when wading across -it. Mayo says "we lean
upon our eyesight as upon crutches," and if we cannot lean securely,
we become giddy.

I shall cite a few cases in which giddiness was the prominent
symptom, partly for the sake of illustration of the subject, partly for
their bearing on other affections.

No. 70. — T. C, set. 55, admitted Feb. 5t.h. Of large make, face red. Ill
four or five moDths with constant giddiness, which is better when he lies
down, and after meals, except breakfast. Has had some rheumatism, but
no gout. Otherwise quite -healthy. P. excited and soft. Marked pulsation
of the abdominal aorta. Sleeps very well. He remained under my care
six months, and during almost all that time there was marked hyperaemia
and heat of head, his hands and feet being cold. He was not at all hyper-
Eesthetic. I exhausted all my skill to relieve his giddiness, but in vain.
Pot. iod., antimony, colchicum, mercury to mild salivation, purging, alkalies,
strychnia, and other tonics failed to eifect any material improvement. Bel-
ladonna (gr. ^ of the extract ter die) made his throat dry, but availed nothing
to lessen the hyperaemia and giddiness. A seton in the neck was the only
measure that accomplished this for a time, but soon it also failed to benefit.
The noteworthy points in the case are the connection of giddiness with hyper-
semia of the head, the absence of any epileptoid affection, and the relief to
the giddiness notwithstanding the hyperaemia in the recumbent position.
The latter circumstance is to be explained by assuming that the effect of
gravitation is more than counteracted by the slower action of the heart, and
the greater steadiness of the head. The absence of morbid excitability in
the encephalic centres was probably the element wanting to give this case
the epileptoid character. This the hyperaemia did not generate.

No. 71. — E. M., aet. 63, admitted Feb. 9th, ill three months. Had smart
epistaxis at first. P. now of fair force. Complains of great weakness, has
not strength at times to speak. Her eyesight fails now and then, she turns
giddy and falls. Much sense of pressure at vertex. Is obliged to lie with
her head high. With strychnia and ol. morrh. continued for some length
of time she got well. This case was clearly one of cerebral debility, yet the
rejumbent position was not beneficial.

VERTIGO. 159

No. 72.— W. C, m., set. 54, admitted June'22d. Ill three weeks. A
short, strong, thick-set man. Was attacked with giddiness suddenly, when
walking about is giddy, feels as if he should pitch downj forehead hot, eyes
dull, is better on lying down. Skin cool. P. soft. B.open. Urine very clear,
pale. T. clean. He had strychnia increased from gr. j\ to gr. ^^ ter die, blis-
ters to the neck and aperients, and quite recovered in two months. The
tonic was certainly the efficient remedy, the others were employed rather to
guard it, on account of the peculiar robust appearance of the patient. In
both the latter instances I think the marked effect of the strychnia shows
that the pathological state was one of cerebral debility, more than of anaemia
general or local. In the latter case there was none certainly, and it was not
marked in the former.

No. 73. — C. C, set. 12, admitted Dec. 11. Ill since about June, when he
was struck on the back of the head with a cricket-bat, and since then has
suffered from dizziness and violent headache, not constantly, but at various
times, and especially if he exerts himself When he is ill in this way he
has repeated vomiting. The attacks last one to two days. No tenderness
of head. Pupils large, active. P. weak. Skin cool. Sleeps well. He
took citrate of iron and quinine with tr. of nux vomica with great benefit.
This case is certainly interesting as showing how the dynamical disorder
remaining after a concussion may be aggravated by expenditure of the nerve-
force, and removed by invigorating treatment.

Among the debilitating causes which produce giddiness none is
more efficient than influenza. It is very remarkable how suddenly
and severely the cerebral affection supervenes, and how long it con-
tinues. In the case recorded at p. 75, it was weeks before the
patient could move his head as usual without feeling dizzy. In the
following case the cause is not so clear, but I think it very likely
that the total abstinence may have predisposed to the attack.

No. 74. — E. W., get. 48, conductor, admitted Sept. 15th. Ill four days
with giddiness and headache, could hardly stand this morning. Has not the
least pain in head, but it feels light, he can scarcely see anything. Is not
anaemic. Says he is a strong man, never ailed with his head till a month
ago. Left off taking alcoholic liquor three months ago. Never drank to
excess. With strychnia he improved very much.

In a case of nearly complete paralysis of both legs and the right
arm from exposure to cold and wet, giddiness was at first a very
marked symptom, and continued for more than a month. Tonics
effected a cure. Venereal excess is often a cause of vertigo, as it is
of epilepsy. A case was recently under my care in which irritable
dyspepsia, general hypersesthesia, and giddiness were very marked,
and had evidently originated from this cause. He was greatly
benefited by nitrate of silver, creasote and opium, and subsequently
by quinine and arnica. The tendency to relapse on leaving off the
quinine was evident. Even when his digestion was fairly good, he
experienced some days giddiness and confusion in the head with a
sense of dulness and temporary double vision. Moving his head
quickly would bring on these symptoms. There is a form of giddi-
ness which occurs in old persons, the nature of which is very obscure,

160 CHOREA.

It appears as a single symptom unassociated with any special state
that can account for it. It occurs paroxysmallj, and is sometimes
quite absent. I will not affirm that it is peculiar to the aged, but I
have not met with it in others. The practical point to be aware of
is that such giddiness is often curable by hydr. bichlorid., given
alone or with tr. cinch. Rheumatism and syphilis affecting the brain
or its membranes may cause giddiness, but, according to my expe-
rience pain is a much more marked symptom in such states. In
numerous instances of renal degeneration that I have met with gid-
diness has been but rarely complained of. Organic disease of the
head is of course often attended with giddiness, but it is seldom, I
think, a very prominent symptom, and the nature of the case is evi-
denced by other and graver phenomena.

CHAPTER XVI.

CHOREA.

Chorea is a disorder of great interest to the student of nervous
affections, inasmuch as its very various and curious phenomena
are not only capable of being explained to a considerable extent
by established principles, but also when duly considered afford
valuable aid to the inquirer into the nature of analogous forms of
morbid action. It is unnecessary for me to give any detailed ac-
count of this well-known disorder. I shall only allude to the facts
of its being sometimes confined to the muscles of one side ; of the
irregular muscular action being sometimes replaced in a great degree
by paralysis, the affection then bearing a notable resemblance to
imperfect hemiplegia ; of the frequent impairment and enfeebling of
the memory, temper, and intellect ; and of the occasional dependence
of the phenomena on some peripheral irritation, such as is occasioned
by pregnancy, dentition, constipation, &c. Some comments on these
facts may be of value. Taking the onesided form of the disorder
we remark that it seems to afford a proof that the encephalon is the
part essentially involved. Unless this were so it would be very dif-
ficult to conceive how the affection should be limited to one-half the
body, which if this be admitted is quite intelligible. The same in-
ference is supported also by the frequent impairment of the mental
faculties, the cessation of the movements during sleep, and by the
circumstance mentioned by Dr. Watson, that he has known it in
several instances to be attended by pain of the head on that side
only which was opposite to the agitated limbs ; the disease also
being speedily cured by local detraction of blood from the painful
part. The enfeebling of the mental faculties, the hemiplegic form

CHOREA. 161

of the disorder, the promoting causes, and the usual "juvantia"
clearly indicate that the disease is essentially one of debility. This
debility is evidently not mere common general weakness, which is
met with every day without any choreic features, but especially be-
falls the nervous system. Chorea is thus most correctly regarded
as a paretic affection of the brain and cord ; but, owing to the great
tendency of weak nervous tissue to irritability, the phenomena par-
take as much or more of undue mobility or convulsion, as of paralysis.
We have here one of the most complete exemplifications of the often-
mentioned law, that irritability and mobility rise as power fails.
The production of the disorder by peripheral irritation appears to
me to afford an interesting instance of inhibitory action, the morbid
impression impairing the functional power of the nervous centres,
and thus inducing a secondary paresis. This is certainly the case
when chorea is produced by intestinal accumulations, dentition, &c.,
but in some instances, among which perhaps those where pregnancy
is concerned should be included, the morbid impression made upon
the encephalon is of a more directly irritating character. Romberg
describes the chorea of pregnant females as almost always bilateral,
the muscles of the face and tongue being invariably affected.' " The
intensity of the movements is very marked, and they are often com-
plicated with convulsions of an epileptic character. Many complain
of a sense of numbness in the affected parts. The brain is almost
invariably affected, and this is shown by headache, vertigo, a wild
expression of the features, rolling eyes, unconnected speech, loss of
memory, and great irritability." The signs of paresis and of ex-
citement are here evidently blended together. In connection with
the production of chorea by peripheral irritation may be mentioned
its repression and cure by sulphuret of potassium baths, which must
act by stimulation of the cutaneous nerves, and rousing of the ner-
vous centres to a more healthy action. Beneke believes that it is
in this way that all baths produce their general effects [v. Schmidt's
JaJirb., vol. cxv. p. 101).

The result of a well- devised tonic treatment in ordinary chorea
is so satisfactory that no question can exist as to the functional
nature of the disorder, and that it depends upon a failure of vital
power, and not at least in the great majority of cases on any morbid
matter circulating in the blood. It may stand as the type of a
great class of diseases, in which a primary alteration of the vital
endowment, a failure or perversion of functional power is the essen-
tial circumstance. As, however, most diseases may arise from dif-
ferent causes, so it may fully be admitted is the case with chorea.
This, as we shall presently see, the test of remedies proves. When
the malady appears to be a simple paresis, a steady use of tonic
treatment is clearly the course to pursue. In most cases I find
citrate of iron and quinine with liq. pot. arsenitis to act very effect-
ually. Cod-liver oil I almost always administer at the same time
in small doses. In some instances strychnia is preferable ; it has

162 CHOREA.

been hi'glily praised by Trousseau, and I have had some experience
myself of its utility. He recommended it to be given in doses suffi-
cient to produce its physiological effects. This I have not found
necessary, but it might be so perhaps in cases of great severity.
The use of the interrupted galvanic current is of great service in
many cases of chorea, and probably might generally be used with
benefit. The two latter therapeutic results increase still further
the rapprochement between chorea and functional paralysis. Cold
bathing judiciously managed is probably second to no remedy in
its calming and invigorating action on the nervous system. This
means should be employed whenever it is practicable. With regard
to cases where the disease is of such severity as seriously to threaten
life by exhaustion, sedatives must be had recourse to. In a very
bad case, detailed by Dr. Graves, morphia with arsenic proved less
serviceable than stramonium with quinine, but recovery seems to be
chiefly attributable to the persevering use of tepid salt water shower
or douche baths three times a day.

Purgation is sometimes of marked advantage. Dr. Prichard states
that he saw a boy who had nearly the aspect of an idiot after a long-
continued and severe chorea restored by a course of purgative medi-
cines. Dr. Hamilton's cases prove that purgation may be curative
even when the general state seems to contra-indicate it. A boy
under his care, get. 8, was emaciated and exceedingly puny, and his
abdomen lank ; but he recovered after having had during ten days
a "most wonderful" discharge of feces nearly equalling in weight
(i)s H. estimates it) that of his whole body. It is very mark-worthy
that the appearance of the feces is sometimes healthy at first, then
becomes unnatural, "black and fetid," and subsequently healthy
again. So that in a case proving refractory to other means it would
be desirable to continue steadily the administration of purgatives for
some time. The best drugs would probably be podophyllin and aloes,
combined with extract bellad. Or aloes with a little blue pill might
be given with extr. nucis vomicae. The beneficial action of purga-
tives may be explained either in accordance with the inhibitory
theory of the disease, or on the supposition that they remove a materies
morbi from the blood. Both views may be true in different instan-
ces. The great majority of my choreic patients have had no indica-
tions of any liability to rheumatism. Of fifteen cases, I find only
one in which there was any valvular cardiac affection, and this
patient is reported never to have had rheumatism or anything like
it. On the other hand, rheumatic affections, though abundantly
common, rarely show any tendency to choreic complication. It is
quite possible that, in some cases, the rheumatic diathesis, whether
that mean a poison (lactic acid) in the blood or no, may be an effi-
cient cause of chorea, just as in certain cases benefited by continued
purgation we may assume the presence of some "materies morbi"
in the circulation, but there is certainly no necessary or intimate
connection between the two disorders. Dr. Kirke's view is that the

CHOREA. 163

association is not between chorea and rheumatism, but between
chorea and valvular disease of the heart, excited by rheumatism.
(V. Med. Times and Gaz., June 20th, 27th, 1863.) He thinks
the valvular disease produces the chorea. Believing as we do that
one important factor of rheumatism is a paretic condition of the
vaso-motor nerves, and that chorea is especially characterized by
a similar state of the musculo-motor, there is certainly so far a
degree of affinity between them. Just as in epilepsy, a certain
predisposition being given, a fright or a worm in the bowels will set
up the morbid process, so it may be that, the tendency to chorea
existing, the exciting cause of rheumatism will evoke the malady.
Other causes will act similarly. Thus M. Zambaco quotes two
cases of chorea depending apparently upon constitutional syphilis,
and ceasing under the emploj'ment of specific remedies. Increasing
experience leads us to attribute a very main part in the causation,
location, and shaping of disease to the previous conditions which
dispose the general system, and the particular part to suffer from
the subsequent morbific influence. The former are the more essen-
tial, the latter may vary greatly, both in kind, and in degree. When
the former are very potent any even a slight exciting cause will, as
it were, explode the mine. When the reverse is the case, the ex-
citing causes must be much stronger, and may often fail to take
effect. Though I am rather digressing I cannot help observing
how these views of the supreme efficacy of the predisposing causes
go to establish the retributive character of very many disorders
which are often imagined to be accidental. We go on a long time
infringing some law of our being, unknowing the while that every
act of disobedience has added to the cumulating force of those de-
ranged vital qualities, which one day some slight cause will call into
terrible activity. The transgression is straightway followed by the
dark shadow of its punishment. Chorea is quite an instance in
point; the permitted indulgence in enervating habits, the neglect to
insure a robust vigorous frame slowly generate the feebleness and
mobility of the nervous system, which is the essence of the dis-
ease. Even though the transgression be rather the result of neces-
sity than of indulgence, as too often occurs among the poor, or has
been the act of a progenitor, the organic law is inexorable. Inflam-
matory affections, softenings^ of the brain or cord, or hemorrhages^
can very rarely be regarded in any other light than as sequelae, or
complications of chorea, and not as causative. Still Dr. Watson's
important observation above quoted should be borne in mind, and
the possibility of the disease being dependent on cranial or spinal
meningitis is perhaps not to be denied. The analogy of epilepsy
would afford some support to this view as we have already seen that
exceptional cases of this disease do occur, in which free depletion is
of marked advantage. In one instance under my care, chorea

' V. Stoffella, Schmidt's " Jahrb.," vol. cxiii. p. 160.
* V. Fuller's case, " Lancet," May 17th, 1863.

164 CHOREA.

appeared as a complication of psoriasis of long standing in a girl,
jet. 12. Both chorea and eruption yielded to arsenic with the aid
of an issue.

Certain cases of chorea are beneficially treated by tartar emetic.
My friend, Mr. Gay, has mentioned to me an instance which had
been treated ineffectually with many remedies, but which recovered
under small doses of this. Gillette' advises it to be given for suc-
cessive periods of three days with intermissions of the same length.
He administers it in increasing doses, so that on the sixth day of its
use, the patient takes 9 grains. Vomiting, and we may presume
prostration, is not desirable. It is probable that the cases where
this medication succeeds are of a sthenic character, and are analo-
gous to those of delirium in which the same remedy proves some-
times so successful.

Regulated gymnastic exercise is often very useful in this disease,
even where it is very severe. For the first three or four days pas-
sive exercise alone is employed, the trunk and limbs being rubbed
and moved. For the next eight or ten the limbs are made to per-
form regular movements, and after this the patients are able to go
to the gymnasium, and pursue systematic exercises. Great improve-
ment occurs during the first ten or twelve days of the gymnasium,
then there is a check, and after this improvement proceeds steadily.
Choreic grimaces and contortions may be treated on the same plan
by making the patient perform regulated movements. The beneficial
effect results no doubt from the improvement produced by the exer-
cise in the functional power of the motor nervous apparatus.

With regard to the curious nerve disorders occasionally met with,
which have more or less resemblance to chorea, epilepsy, and hys-
teria, as I know nothing of them from personal experience I shall
only remark that they seem either to be connected with irregular
menstruation, or to be produced by imitative sympathy, or by some
morbid emotional excitement. Probably in most of these cases the
liberal employment of cold affusion, both actually and metaphori-
cally, would powerfully tend to arrest the morbid manifestations.
Nothing we know promotes such proceedings more than sympathy
and attention, and nothing is more decidedly repressive than
" throwing cold water" upon the exhibition. Bricheteau^ gives an
account of an epidemic of chorea in one of Monneret's wards.
Eight females contracted the disorder from the spectacle of one
who was severely affected in the course of five days, and more would
probably have been attacked had not the contagious influence been
arrested by isolating the patients. Constans' records the oc-
currence of an epidemic of hysterical demonomania. The inhabi-
tants of Morzines in Haute Savoie, amounting to about 2,000, live in
a state of great poverty and bad hygiene. The epidemic lasted four

« " Ann. de Therap.," 1859, p. 102.
2 "Gaz. des Hop.," No. xlvi., 1863.
s " Med. Critic and Psycholog. J.," Jan. 1863.

PARALYSIS AGITANS. 165

years and affected as many as 110 persons. They were termed
possessed, were mostly celibates, chloro-anseraic, or scrofulous, and
suffered from gastralgia or dysmenorrlioea. Everything gave occa-
sion for a paroxysm, especially the expression of a doubt that they
were possessed. The phenomena were partly hysterical, partly
maniacal. The affected retained sufficient consciousness not to
injure or expose themselves in the most disordered actions. The
epidemic was arrested by removing the priest, and intimidating the
people by the presence of soldiers. The influence of diseased morale
is sufficiently apparent here.

CHAPTER XVII.

PARALYSIS AGITANS.

It appears to me a question whether two distinct affections are
not often comprehended under this name. For on the one hand it
appears pretty certain that there is one form which is met with in
old persons, is quite incurable, and is associated with if not depend-
ent on organic wasting changes in _^the nervous centres ; while
another form occurs in younger persons, is more curable, and there-
fore is presumably not dependent on organic change. Stoffella^
relates the case of a man, set. 79, who had the affection five years
before his death. At the autopsy he found traces of atrophy of the
brain with secondary dropsy of the ventricles and of the cerebral
membranes, and an apoplectic cyst as large as a pea in the right
optic thalamus ; the pons Varolii and medulla oblongata were re-
markably stiff, the arteries at the base calcareous, and the lateral
columns of the cord, especially in the lumbar region, traversed by
grayish opaque streaks, which as well as the indurations in the pons
and medulla resulted from embryonal connective tissue. Cohn, who
has recently published a paper founded on an experience of six
cases, gives two autopsies,^ in one of which there was marked cere-
bral atrophy, and in the other wasting of the cord opposite the
second cervical vertebra. The ages of the patients, both males,
were 49 and 74 years. The first had been employed in using
mercury. Skoda^ details the autopsy of a female, 83t. 34, who had
been affected about 2|- years, and died of variola. The brain was
tough, the pia mater oedematous, the walls of the ventricles, the
fornix, pons Varolii, medulla oblongata, and cord were remarkably
stiff, both optic nerves were flattened and stiff. In some opaque
reddish spots in the brain the nerve-tissue was destroyed by embry-

1 Schmidt's "Jahrb," vol. cxiii. p. 39. 2 Ibid., vol. cviii. p. 303.

3 Ibid., vol. cxix. p. 294.

166 PARALYSIS AGITANS.

onal connective tissue, which occasioned also the induration of the
pons and medulla. The muscles were very fatty, the neurilemma of
the nerves of the upper limbs was thickened.

The following histories may serve as examples of the more cura-
ble forms of the disease. A male/ set. 57, came under Dr. R. Rey-
nolds' care suffering with vertigo and general disturbance with
paralytic tremor of the whole right upper limb, which in the situa-
tion of the biceps was 4° F. hotter than the other. The sensibility
was unaffected. After five applications of an 120-link Pulverma-
cher's chain each lasting an hour the spontaneous jactitation com-
pletely ceased. By continuing the same treatment every other day
the power of the arm was almost quite restored in a month. The
disease was recent, having commenced only fifteen days before he
was submitted to treatment. Graves^ gives the case of a female,
set. 25, who after a severe fright became vertiginous and hemiplegic
and was laid up in bed three months. The hemiplegia gradually
declined, but the muscular power remained weak, and very imper-
fectly under voluntary control, most of the muscles being in a state
of perpetual motion. Amaurosis also affected both eyes during the
disease, but one recovered completely, the other very imperfectly.
She could not walk slowly, and when she had commenced walking
she could not stop without considerable difficulty. The following
cases have come under my observation at St. Mary's, the two latter
being under my own care.

No. 75.— S. M., f., set. 12, ad. April .3d. Of healthy aspect. Ill three
months with catarrh and cough, last three weeks has had vomiting which
has got worse. She rejects everything which she takes shortly after swal-
lowing it, but has no pain in the stomach. Slight epigastric tenderness.
B. costive. T. whitish. Much thirst. P. 70. Appetite good. Her right
arm is in continual vibration ever since her illness commenced. Lung and
heart sounds healthy. 4th. I found her asleep to-day and her arm quiet.
She had two purges of calomel and haust. sennse. On 6th she was electro-
magnetized for about ten minutes, and in about one hour after the arm
became quiet, and has remained so ever since, and the vomiting also has
ceased. 13th. Discharged.

No. 76. — J. K., labourer, aet. 60, ad. March 16th. A broad-made,
strong-looking man, not anaemic. Had rheumatic fever seven years ago,
not so well since. Thirty years ago he was frightened by a bull who tossed
him into a hedge, and he has shook ever since. His hands and arms
tremble, his hands shake so that I cannot feel his pulse. He has pretty
good muscular power in his arms. He does not seem to have been intem-
perate. He only attended a short time on account of some lumbar rheu-
matism.

No. 77. — J. H., set. 47, labourer, ad. Sept. 24th. Is a large man.
Complains of tremor of the right upper extremity ; the muscles of this limb
have full power, but quiver and twitch constantly except while he is quiet
as in bed ; the pectoral muscles of that side are involved. There is some

1 Schmidt's " Jahrb.," vol. cxix. p. 294. 2 "Lancet," Dec. 3d, 1859.

PARALYSIS AGITANS. 167

tremor of the legs, but nothing like that of the arms. Both however are
decidedly weak ; the knees are sometimes very stiff. No numbness of the
right arm, but has pins-and-needles sensations in hand sometimes. When
the shaking stops he has aching in the right scapula, and along the biceps.
No pain or tenderness in the spine. When first attacked his eyes were
always " winking," not lately. Sight and hearing are quite good now, but
his speech, memory and vision are occasionally impaired. The least excite-
ment makes him worse. He sleeps, eats, and drinks well. Sweats very
easily, much at night. Was affected in the same way two years ago, was
under my care and soon got well, remained quite well for one year, then the
disorder came on again at intervals ; some days he would have it and others
not. I gave him at first strychnia, iron and ether, and faradized his arm.
This treatment, especially the electricity, was rather injurious than otherwise.
I changed it after eight days for tr. hyoscyami 3ss t^f d^^j under which
he rapidly improved and ceased attendance in a fortnight.

Petrseus^ relates two severe cases, observed in the Copenhagen
Hospital, one of which proved fatal. Nothing was found at the
autopsy but fatty degeneration of the heart, and pneumonic con-
solidation of the right lung. He remarks on the tremor not being
constant in many cases, ceasing for some days and then recurring
with fresh force ; or changing its seat from one part to another.
The tendency to steady increase is, he thinks, specially character-
istic of the disease. All weakening influences whether of mind or
body are apt to produce the disorder. Cohn distinguishes tremor
from paralysis agitans. He considers the first as paretic debility
and not as a spasm ; and derives it from failure of the tone of the
voluntary muscles which they receive from the nervous system.
The causes of spasm and of tremor are the same. Paralysis agitans
he considers as tremor complicated with palsy, the latter involving
even the muscles concerned in swallowing and the sphincters, and
being attended with anesthesia. The paralysis generally super-
venes at an advanced period of the disease and is usually less
extensive than the tremor. Both Cohn and Copland consider mer-
curial tremor as an example of paralysis agitans. Frank^ relates
the case of a widow, set. 40, who after exposure to cold on coming
out of a vapour-bath was attacked with this disorder. The move-
ments seem, however, to have been more active than usual, and as
she recovered in no long time after cupping the spine it may be
doubted how far the case is comparable to the chronic affection.

It appears to me that the cases I have cited warrant the view
that there exists a functional nervous affection which at least bears a
very close resemblance to paralysis agitans. Between this state and
chorea there is certainly no very material difference. From the
success of the continuous galvanic current in Reynolds' case, and of
henbane in my own especially after faradization and strychnine had
failed, it seems probable that the disorder depends in some instances

' Schmidt's ".Jahrb.," vol. cxvii. p. 163.
2 Copland's Diet., art. Paralysis, p. 25.

168 PARALYSIS AGITANS.

at least on increased excitability of the nervous centres of such a
quality that it will not tolerate tonics, and requires rather calmants.
This varying quality of nervous matter is just one principal thing
that makes the treatment of epilepsy and its allied disorders so un-
certain and diflScult. Whether the slighter forms of the affection
may pass by long continuance into the graver and more incurable,
attended with organic change, is difficult to determine, but I think it
quite possible. The analogy of chorea, which, as we have seen, is
complicated sometimes with decided morbid changes, is very confir-
mative of this view. Prolonged restless excitement of the nervous
tissue in the centres is very likely, as in epilepsy, to induce a local
determination of blood which gives rise to slow exudation and indu-
ration. It is somewhat remarkable that these changes affect the
same localities in paralysis agitans, as they do in epilepsy. The
wide difference between the irregular purposeless tremors of paraly-
sis agitans, and the strong, steady contraction of a muscle in volun-
tary effort needs no exposition. It is clear that no theory can be
correct which would class them together, because in both there is
muscular action. The one circumstance common to both is that
some disturbance of the molecular state which the nerve-cells assume
during quiescence occurs in each. In the one this disturbance is
perpetual except during sleep, owing probably to deranged nutrition
of the nerve-cells. In the other the disturbance is regulated by the
wnll, and is compensated by sufficient repose. The tendency of a
habit of action, as well insisted on by my friend Dr. Sieveking, to
perpetuate itself and become inveterate is not to be left out of
account. The tremor, which at first, excited by some casual cause,
might by appropriate means have been stilled permanently, when
allowed to become habitual exceeds our power to control. The
treatment of paralysis agitans in its earlier stages must I think be
substantially the same as that of chorea. In its later, though there
can be small hope of benefiting the patient materially, I should use
hydr. bichlorid. in tr. cinchon. with ol. morrh., and sulphuret of
potassium baths.

As mercurial tremor has been alluded to above as a species of
paralysis agitans, a view in which I quite coincide, I will observe
here that mercury may be regarded with good reason as a very
poison to feeble nervous systems. The disorder of the motor nerves
which it produces is essentially a chronic affection, as evidenced by
the similarity of the symptoms, the existing debility, the "Igedentia,"
and the " juvantia." Dr. Watson writes that it is aggravated by all
kinds of mental emotion, and relieved temporarily by anything that
tends to stimulate and fortify the nervous power. Steel is one of
the best remedies for this disorder as it is for chorea and other
neuroses. The inflammation of the buccal mucous membrane
induced by mercury is evidently not of phlegmonous character, but
of diffuse, and quasi-erysipelatous. It may be referred, I think, very
reasonably to a paralysis of the vaso-motor nerves of the part.

SPASMODIC AFFECTIONS. 169

Eczema mercuriale is a similar affection of the skin ; it is apt to be
attended with adynamic fever, and sometimes with delirium and
convulsions. The practice of taking or giving frequent blue-pill
aperients is worthy of all reprobation.

CHAPTER XVIII.

SPASMODIC AFFECTIONS.

IIypercineses, as Romberg terms them, seem to be of rarer occur-
rence than the corresponding hypersesthesige. The same may be said
of the kindred paralyses as compared to aneesthesia and neuralgise.
This is somewhat remarkable inasmuch as in organic disease the rela-
tion is reversed, motor power is much more frequently impaired than
sensory. In many cases spasms depend on some organic alteration,
but in quite as many they are independent of it. They present two
principal forms, viz., clonic and tonic; the latter are more often the
result of asthenic excitement than the former. In all spasms there
is a defect of volitional power, the cerebral centres no longer rule
the actions in an orderly manner, and some of the lower centres
seem to have usurped their authority. In some instances the
emotional are the seat of morbid excitability, in others the spinal.
Often the excitability is intimately connected with debility, but this
is by no means necessarily the case. Remote irritation, in the
intestines or elsewhere, is a frequent determining cause of the spasm.
Romberg in his first volume has given one of the best accounts we
possess of the different manifestations of spasm. I shall notice briefly
in this place the less commonly recognized forms, having described
the classical elsewhere.

Trismus is a clonic or tonic spasm of the muscles concerned in
the movements of the lower jaw, and sometimes of the adjacent. It
may be produced in predisposed persons by cold. One of Romberg's
patients, a male, set. 43, is subject to a dying away in a marked
degree of the upper and lower extremities accompanied by numbness
of the muscles. At the same time the masseters and the tongue
become rigid, and there is dysphagia. These symptoms are brought
on immediately by exposure to cold. Evidently spasmodic contrac-
tion of the arteries of the limbs coincides, in this instance, with a
like state of the masticatory and lingual muscles. Various other
causes may produce trismus, as dental and intestinal irritation, epi-
lepsy, the gouty diathesis, abscess in the abdominal parietes, and
hyper-excitability of the nervous centres. Dr. Eraser relates a case
of severe trismus resulting from exposure to wet and cold, which was
treated beneficially with Cannabis Indica given in gradually increased

170 SPASMODIC AFFECTIONS.

doses up to gr. iij, o. li. He improved gradually, and made a good
recovery. (V. Med. T. and Gaz., Feb. 7, 1864.)

Facial spasm may show itself in one or several of the muscles
supplied by the seventh nerve. It may aifect the orbicularis palpe-
brarum alone, or the buccinator. A patient under my care, suffering
with periodic frontal neuralgia attended with giddiness, had also
twitching of the left eyelids. The pain and giddiness were cured
by iron -\- quinine, but not the twitching, nor was the endermic ap-
plication of morphia more effectual. A lady, who had had chorea
when a girl, and whose nervous power was weak and overtasked,
suffered with twitching of the face, her mouth being frequently
drawn awry so that she had to hold it with her hand to steady it.
She was wonderfully better in frosty weather. Immediately on
eating, her face and neck became quite flushed and crimson. Here
we have a paresis of arteries associated with a clonic spasm of ad-
jacent muscles, the vasomotor and musculo-motor nerves being no
doubt in a like state. MitchelP records the case of a female, aet.
60, in whom the muscles of the face, and tongue, and neck on the
left side were affected at intervals of ten minutes, with rigid spasm
lasting for three minutes at a time. The left side of the nose and
chin was numb, the teeth were closely compressed, the nose was
drawn over to the left side, and the forehead and eyebrows corru-
gated. The muscles of the neck rotated the head to the left shoulder,
the left arm became extended, and a sense of numbness ran down
in a straight line from the neck to the thumb and forefinger. The
disorder ceased after the extraction of all the carious teeth. Rom-
berg had under his care a robust man, set. 36, who after a powerful
mental emotion was attacked with slight paralysis of the left side.
This disappeared after bloodletting and purging, but violent spasm
set in, affecting exclusively the left half of the mouth and the pla-
tysma myoides ; it persisted for four days and nights, and gradually
yielded to cupping and tartar emetic, and the endermic application
of morphia. Oppolzer^ relates a case in which along with pain of
the right side of the head and face, and right shoulder twitchings
occurred in the facial muscles, the sterno-cleido-mastoid, the muscles
of the external ear, and those of the shoulder. The muscles of both
external ears were affected, the right most. The twitchings were
attended with severe pain which preceded and outlasted them. Pres-
sure on any part of the face, or head, or shoulder, arrested the
twitchings, but not the pains. Volition also controlled the spasms.
In the preceding cases we have examples of the causation of facial
spasm by simple nervous hypersesthesia, by remote irritation, or by
sthenic excitement of the brain (probably). It is evident that much
discrimination is requisite to judge correctly of the pathological
state.

Strabismus is sometimes a spasmodic affection, and is produced

1 "Med.-Chir. Trans.," vol iv. p. 25. ^ "Wien Wochenbl.," 6—8; 1861.

SPASMODIC AFFECTIONS. 171

by dental or intestinal irritation, by inflammatory disorder at the
base of the brain, and by any emotions which temporarily derange
mental equanimity. Bohm states that idiots whose eyes were in a
normal state at other times squinted egregiously while engaged at
their lessons. As the cerebral power increases the squint lessens and
disappears. This seems to indicate a diversion of vis yiervosa from
the centres of the ocular nerves to the weak and struggling hemi-
spheres. The same author relates an interesting instance of the
replacement of ague paroxysms by spasmodic strabismus. The type
was at first quartan, then tertian, and lastly quotidian.

The muscles of the neck are not unfrequently affected with spasm,
which is often produced by rheumatoid influences, but in other cases,
as in that related by Brodie, where a wry-neck alternated with
melancholia, seems to depend on dynamic nervous derangement.
In one of Romberg's cases dentition was evidently the cause of the
spasm. In a weakly girl, set. 7, under ray care, there was very
marked tonic contraction of the left sterno-cleido-mastoid. The
head was drawn to the left, much more so at some times than at
others. Under the use of iron, ether, and valerian with veratria
ointment locally the spasm ceased, recurred again with earache,
and ceased again under the administration of pot. iod. + ammon.
carb. There was a rheumatic element in the case as evidenced by
some affection of the feet.

The two following cases are instances of spasms probably originat-
ing in the upper cervical region of the cord, of very obscure causa-
tion, and but little modified by treatment.

No. 78.— E. B., get. 43, seen Oct. 3d, 1862. Has been affected for about
twelve months as at present, his health, however, remaining good. Is a
broad-made man with rather short neck, works at china-riveting, and thinks
his work may have something to do with the disorder, as he sits with the
right side of his head facing a window, and has to turn frequently to the
left. He is subject to almost continual clonic spasm especially of the left
sterno-cleido-mastoid and trapezius muscles, by which the head is bowed to
the left side and the shoulder is raised. Any mental excitement increases
the spasm greatly. He is much worse sometimes than at others. He has
a sensation of cramp in the left neck which extends down the outer side of
the same arm, and is relieved by stretching it out. The muscles of the
right side of the neck do not appear to be paralyzed j he can straighten his
neck occasionally by a voluntary effort. In June, 1863, he had an attack
of rheumatism of the right leg. April 5th, 1864. Is much better since he
went down to Brighton last autumn and had sea-bathing ; while in the water
he was quite free from spasm, and so he is now in the morning and when he
is warm, but on cold, wet and foggy days he is worse. The spasm is very
much less than it used to be. Much treatment was employed in this case
with but little advantage, he took ferri carb., zinci valerian., tr. aconiti, pot.
iod., and citrate of quinine and iron, but with very little advantage. Sub-
cutaneous injections of atropine and opium were fairly tried, but they dis-
appointed my expectations. Galvanizing was apparently of benefit, the
antagonist muscles being faradized, and the affected ones subjected to a

172 SPASMODIC AFFECTIONS.

continuous current. This was done under Mr. Lobb's supervision. On tbe
whole I think the " vis medieatrix" had as much share in the improvement
as the remedies. The affection seems to be specially referable to excitement
of the left spinal accessory nerve, but there is nothing to show how this
originated. May not such states of excitement arise in nervous centres
apparently sua spnnte, just as they seem to do in centric epilepsy ?

No. 79.— St. W., get. 33, f., seen Nov. 14th. Aspect " spiritual." Has
suffered a long time with indigestion, does not often vomit. Feels sinking
in fifteen minutes after food as if she had not taken any; this is relieved by
spt. ammon. fetid. Is not anaemic. B. very costive. P. above 100.
Urine clear. Catam. regular. She suffers with attacks of vibratory move-
ments of head, sometimes of arms, which are made worse by the shower-
bath. At times has paroxysms of violent spasmodic contractions of the
diaphragm resembling hiccup attended with constant expectoration of white
frothy mucus. I witnessed one of these, which lasted some minutes and
appeared very distressing. They continued sometimes a quarter of an hour
and were succeeded by sensations of sinking. The vibratory movements of
the head from side to side were much more continuous than the spasms of
the diaphragm, they occurred sometimes while she was lying down. There
were sometimes intervals of four to eight days between the paroxysms.
During one fortnight they occurred very frequently, she could not take any-
thing even water without bringing them on. Her nights were restless.
She had sometimes pain and throbbing in head. She could not walk
without some slight assistance, as a finger held out to her. Her disorder
did not seem to be at all simulated, in fact both the cervical and the
diaphragmatic spasms were clearly involuntary. She remained under obser-
vation till towards the end of the succeeding March and was then dis-
missed materially improved ; she could walk a good deal better. The chief
remedies employed were aperients, citrate of iron and quinine, and iron
electuary. The pulse varied from 108 to 132. It seems most probable
that this was a dynamic disorder, and also that it was not dependent on
remote irritation. Had it been otherwise the progress would rather have
been to worse than better. I think we must assume the existence of a state
of erethysm of the cord in the vicinity of the origin of the phrenic and upper
cervical nerves. Counter-irritation in both these cases would probably have
been advantageous, in fact in the latter the head was much quieter some
time after a blister to the loins.

The following case was, I think, closely related to neuralgia, or at
any rate to neuralgic disorder, judging from the aneesthesia and the
" juvantia." It was probably a peripheral neurosis, but is of interest
specially as showing the affinity between spasm and paralysis
(sensory).

No. 80. — A. N., f., set. 17, got suddenly spasmodic contraction of the
flexor muscles of the left hand and forearm a week before she came under
Mr. Bryant's care. The health was good, catamenia regular, sensation of
the parts perfect. Iron was given, and in three weeks the natural move-
ments of the part were restored; the nerves of sensation, however, now
became involved, complete anaesthesia of the whole hand and forearm making
its appearance. This condition also disappeared in two months under the
same treatment, sensation and motion being at last perfect. (V. lied. Times
and Gaz., 1862, June 14th.)

SPASMODIC AFFECTIONS. 173

The affection termed writer's cramp seems to depend on undue
excitability of the muscles and nerves concerned in writing, such
that they are unable to execute the necessary delicate movements,
but start off into larger ones. When much engaged in writing
during cold weather I have experienced a tendency to it, which
makes it needful to write more slowly and steadily in order to keep
the muscles under control. There is at such times a sense of fa-
tigue in the hand and wrist, and for some way up the arm. Zura-
delli considers that there is primary paralysis of some muscles, and
secondary spasm of others, and that various forms of the disorder
may occur according to the particular muscles affected. Thielmann
relates a case of similar disorder occurring in a sempstress. When
she attempted to sew, the thumb flew away from the needle, and a
burning pain extended up along the outer side of the wrist to the
elbow, and if the effort was continued a red streak formed in the
same situation. She was cured in twelve days by quinine and
opium. Haupt states that other neuroses are not infrequent as
complications of writer's cramp. He mentions squinting, stuttering,
choreic disorder, laryngeal or pharyngeal spasm, strangury, palpi-
tation of the heart, solar plexus, neuralgia, headache, &c. Rheu-
matism appears to be one of the inducing causes, over-exertion of the
muscles concerned, and general impairment of nervous power in-
ducing undue excitability are also powerfully influential. It is
evident that resting the enfeebled part is necessary, and in many
cases if not indeed in all, I should strongly advise the patient to
discontinue entirely writing with the affected hand, and to accustom
himself to use the other. This would not cause much inconvenience
after a few weeks' practice. Pitha relates a case cured by electri-
city. Chorea, which is so analogous a disorder, is sometimes so much
benefited by faradization, that I should expect much good from the
same means in writer's cramp. Dr. Althaus employs the interrupted
current when the disorder appears to be paralytic, but the continu-
ous if it is spasmodic. I have no doubt that the latter remedy is
especially indicated in spasms due to sthenic excitement, but where
the condition is rather one of hypersesthesia and debility the stimu-
lus of the interrupted would be I think more beneficial. It is cer-
tain that some spasms are cured by stimuli. Tonic or sedative treat-
ment internally would also be very advisable. In cases where there
was any indication of a rheumatic element potass, iod. usually with
ammon. carb. should be administered. Cold douching would proba-
bly be beneficial, and local bathing with sulphuret of potassium
lotion.

Spasms of the muscles of the lower limbs, especially of the
gastrocnemii, are not uncommon, and give rise to various distortions.
Remote causes of irritation are probably the most frequent, but in
some instances there is centric disorder. It is remarkable that in
some cases the weight of the body pressing on the feet against the
ground seems to have induced the spasm which was absent in the

174 SLEEPLESSNESS.

recumbent posture. This illustrates the reflex production of certain
distortions. Bamberger relates the case of a youth, set. 19, conva-
lescent from pneumonia. As soon as he touched the ground with
his feet all the muscles of the lower extremities fell into a state of
tetanic rigidity, interrupted by the most violent sudden contractions,
which threw the patient upwards, and during their rapid recurrence
increased in intensity so that the patient had to be supported. At
the same time the face was flushed and distorted, the pulse accele-
rated and extremely forcible. The moment that the patient sat or
lay down all the movements ceased. If while lying in bed the soles
of his feet were pressed, the same phenomena appeared but with
much less intensity. He was cured by sedatives and cold affusion
{v. Schmidt's Jahrb., vol. cii. pp. 23, 24). The congenital
development of pes equinus, &c., which is not infrequent, stands
probably in connection with the greater tendency to reflex action
during fcetal life in consequence of the imperfect control exercised
by the brain.

The most practical facts to bear in mind with reference to spasms
are, (1) their frequent dependence on some removable cause of irrita-
tion ; and (2) that when there exists no such exciting cause the
quality of the nervous derangement producing them may be very
various, either sthenic requiring depletion and counter-irritation, or
hypergesthetic calling for sedatives, or connected with exhaustion
and needing stimulants and tonics. It may be no easy matter to
estimate correctly the existing pathological state.

Mr. Smith, of Leeds, finds that permanent involuntary contrac-
tion of muscles may be successfully treated by the following simple
proceeding. Place their origin and insertion as far apart as
possible ; maintain them in that state for some time, their oppo-
nents will then be gaining strength, and the balance of power will
be restored. He states that he has cured cases of spasm of the
masseter, sterno-cleido-mastoid, and various other muscles by this
means. {Lancet, Sept. 20th, 1851.)

CHAPTER XIX.

SLEEPLESSNESS.

The requirements of different individuals with regard to sleep
differ considerably. Some are able to do with comparatively little,
others need much more. It is generally those of great mental and
nervous energy who at any rate for a certain ,time can bear the
privation of their ordinary repose. Alison says of Napoleon, that
like Wellington and all great generals he had an extraordinary

SLEEPLESSNESS. 175

power of commanding sleep when it suited him to take rest, and of
doing without it when circumstances required such a privation.
Boerhaave, according to Forbes Winslow, is recorded not to have
closed his eyes in sleep for a period of six weeks in consequence of
intense study. We may perhaps take this account cum grano salis,
as we read in a note of the same page that a Chinese criminal lived
but nineteen days when condemned to be put to death by being kept
constantly awake. There is, however, no doubt that in the state of
mania patients will pass an extraordinary length of time with little
or no sleep, and that all very strongly exciting passions and emotions
will have a similar effect. The above remarks may seem to show
the propriety of distinguishing a sthenic variety or form of sleepless-
ness depending on cerebral excitement, or on a state of semi-inflam-
matory irritation. It has much in common with the sthenic form of
delirium tremens, and occurs in various fevers, in inflammations of
the cerebral membranes, and in commencing insanity. Mr. Solly
reports a case where repeated copious leeching with purgation fol-
lowed by gentle mercurials and aconite produced sleep in about five
days, of which otherwise there was but little prospect. Dr. Graves
also mentions a case of delirium tremens in which watchfulness was
a prominent symptom, but disappeared rapidly under the use of tar-
tar emetic with opium. Such cases are, however, comparatively
rare with regard to those of the opposite type where the sleeplessness
is dependent upon a state of debility and irritability induced by
bodily or mental causes. Dr. Russell has published an excellent
paper^ in which he illustrates forcibly the powerful influence of
mental excitement and trouble in causing sleeplessness. The eff'ects
of such inflictions are only too familiar, and too often are the secret
cause why the best therapy proves inefficient. When, however, the
depression is not yielded to and encouraged, or is not too over-
whelming in proportion to the strength of the system, judicious
medication may often do much to make the burden less felt, the
edge of the sorrow less keen. It is most true, and Dr. Russell illus-
trates it well, that the feeble hypersesthetic brain collapses under
the pressure which an organ of better quality and power can sustain.
Now we have means whereby we can often improve this quality and
power to a greater or less extent. Further, the mere procuring a
regularly recurring oblivion of distressing impressions is no slight
boon, and makes the suff'erer more capable to bear his waking bur-
den. Our nature is so compounded of the material and immaterial
that what benefits the former is almost certain to do the same to the
latter. A girl recently under my care with very various and
marked signs of prostration of nerve-power suff'ered for many months
with exceedingly restless nights, the cause of which appeared to be
chiefly great hypersesthesia. Although she improved materially in
other respects she did not sleep well until she was removed from

» "Brit. Med. J." 1861 ; May 25th, Nov. 9th, 16th.

176 SLEEPLESSNESS.

London to a healthy part of the country. I have had several patients,
two especially, both temperate males, who for a length of time were
quite dependent for good rest at night on wine taken either on going
to bed, or in the course of the night. Graves mentions that in per-
sons of irritable and nervous disposition he has found musk or assa-
foetida given more or less frequently during the day effectual in
procuring sleep at night. In some cases of this kind it answers
well to divert the patient's attention from the idea of remaining
sleepless by giving it a new direction, as the importance of being
awake to take his medicine at fixed times. In others a placebo, such
as a bread-pill, proves a powerful sedative if only the patient can be
inspired with faith in'^its efficacy. Dr. Lay cock mentions a case
where so long a sleep followed such a medication that it excited
alarm. It is not easy to form a precise idea of the state of the
nervous centres in which "a night-cap," as above mentioned, is so
effectual in procuring sleep. Debility is certainly one marked fea-
ture of it, but there must be surely another, even more important,
as the most profound debility does not by any means always inter-
fere with sound sleep, nay, rather seems to conditionate it. This
other element we are much disposed to think is hyperaesthesia, or
irritability, which as already noted so commonly increases pan passu
with weakness. The condition may be compared with that of neu-
ralgia when it is beginning to give way under treatment, and is so
easily reproduced by anything that causes exhaustion. Now as the
stimulant recruits the exhausted nerve-force the hyperaesthesia
ceases, and the brain-tissue subsides into a state of calm repose. It
may be added here that it is often well to give not only a stimulant,
but also some digestible nourishment, about the time of going to
rest, or even in the course of the night where debility to a serious
extent exists. It is quite certain that a craving empty stomach is
by no means favourable to quiet slumber, and in this point of view
moderate suppers are far from being unsuitable to many invalids.
I well remember the case of a lady, who the night after a natural
confinement woke up with severe gastric disorder and flatulence,
which resisted various medication, but subsided immediately after a
plate of cold meat, and some brandy-and-water.^ Among the
various soporifics I doubt if there be any more potent, especially for
the weakly and hypersesthetic, than prolonged exposure to the cold
open air. This should be so managed as not to cause great fatigue,
and if well timed, and followed by a sufficient meal, it will be found
an admirable preparative for sound nightly slumber. Where this is
impossible, as in cases of severe disease, and especially where, as
often happens, narcotics disagree, it is well to try the effect of a
monotonous voice. There is no question as to the soporific influence
of such tones particularly when the speaker or reader is detailing

' A medical friend informs me that he finds a mustard poultice to the epigastrium
an excellent hypnotic in some cases. This probably depends on its stimulating a lan-
guid solar plexus.

SLEEPLESSNESS. 177

some matter ^vllicll is not without a considerable tinge of dulness.
The old monk's prescription for sleeplessness, viz., to tell your beads,
was sound advice. The removal of any existing cause of irritation
is of course often essential to procure sleep. Surgical cases exem-
plify this well. A gentleman about whom I was consulted lately
told me that while suffering with torpid liver in India he had no
sleep for five months until he commenced the nitro-muriatic acid
bath and sponging. He thinks that he never slept an hour, and
besides bad lost taste and smell. He had no jaundice all this time,
but objects appeared yellow to him. In less than a fortnight the
function of the liver was restored, and with it the senses of taste
and smell. Then followed sleep, at first for thirty hours on end,
and in six months he was in perfect health.

The conditions necessary for the sleep-repose of the brain seem
to be essentially these two, (1) a non-excited or active state of the
cerebral tissue ; (2) in most cases a diminished aflux of blood to the
organ. We have already sufficiently noticed the importance of the
first ; the following observation illustrates well the need of the
second. A gentleman, set. 24, after considerable mental strain,
experienced the following symptoms. He was thoroughly weary
and drowsy at the close of the day, and felt, as well he might, the
need of nature's restorer; scarcely, however, had he laid down his
head, when the cerebral arteries began to throb forcibly, and soon
all inclination for sleep was banished, and for hours he lay wide
awake but deadly weary. The causa niali here was evidently defi-
cient tonicity in the cerebral arteries, or more exactly paresis of
their vaso-motor nerves. As the arteries relaxed they admitted an
undue flow of blood to the brain which goaded its weary tissue into
abnormal activity. The effect of altered blood-flow on the brain is
also apparent in the following account which Graves quotes from
Vigne's work. He states that in Kashmir it is a common practice
for mothers to put their children to sleep by exposing the head for
two or three hours to a small stream of water. This, as in Brown-
Sequard's and Tholozan's experiment of lowering the temperature
of one hand by chilling the other, must certainly have the effect of
causing cerebral anaemia by contraction of its arteries. In children,
attacks of malaroid remittent, a disease I shall subsequently describe,
are invariably productive of very marked sleeplessness. The noc-
turnal febrile paroxysm seems to generate a state of excitability of
the brain, and at the same time to stimulate it to morbid action
by accelerating the circulation. Quinine in these cases is a most
efficient hypnotic. Adults also occasionally suffer much with rest-
lessness at night in connection with obscure aguish phenomena, as
chills, cold sweats, prostration, and feelings of alarm, or strange
terror. In some instances of this kind there is that very peculiar
sensation of dread which makes the person afraid to sleep lest it
shiould be a sleep without waking. I have met with this in both
sexes. Closely allied to the insomnia of fever is that which occurs
12

178 SLEEPLESSNESS.

from over- fatigue, where the sufferer, though sorely in need of repose,
lies vainly expecting it, and finds himself instead wakeful, feverous,
and exhausted. Tea-drinking, though in moderation, will sometimes
seriously interfere with sleep. I believe the following is an instance
of its poisonous action when taken in excess.

No. 81. — J. R., 3et. 47, m., a large stout man, works at a kila in a brick-
field, ad. April 27tli. Ill one month. Complains of a tormenting feeling
which goes all over his chest and head, and prevents sleep; when he does,
he has terrific dreams. Does not suffer more after eating. T. clean. P.
quiet. B. not regular. Sounds of heart normal. Sanguine aspect. Slight
rheumatic pains in the knees. His symptoms did not vary much ; he con-
stantly complained of a tormenting feeling "like evil spirits," referred to the
praecordia, and attended with palpitation. He was besides weak, and had
some tenderness of the scalp and some lichenous eruption once. I was
quite unaware of the nature of the case, and gave him various medicines
with little or no benefit till June 22d, when as he complained of being rest-
less, at night I ordered him half a grain of morph. mur. o. n. and a mixture
of tr. valerian, aramon. + tr. arniege + tr. opii ter die. He improved by
this, and was quite well by Aug. 3d. His wife told me then that she had
thought he was out of his mind; he vised to lie awake at night with-
out sleep ; fancied he was going to be taken away to an asylum. He
wanted to tell the hospital chaplain that he was going to be stoned. His
illness began with nocturnal restlessness and sleeplessness. He was never
a drinking man, but used to drink last summer three or four quarts of tea
a day while at work. After his recovery he was conscious of his former
delusions. From the praeeordial dyssesthesia, and the sleeplessness, and the
good effect 'of morphia I am strongly inclined to regard the preceding as a
tea-neurosis. The history is unfortunately deficient as to whether he had
continued his copious libations of tea up to the time of his being taken ill,
and as to whether he subsequently discontinued them, but the probability
is that he made no change. In all obscure neuroses we ought to consider
whether tea may not be the culprit.

With regard to soporific drugs I think that henbane, In spite of
the doubts which have lately been thrown upon its efficacy, approves
itself frequently as a really valuable remedy. It seems to act as a
direct cerebral calmant, affecting evidently the vaso-motor system
in a much less degree. It is rare that it has any injurious effects,
but I have met v/ith some very susceptible systems, who could not
take it nor any other form of narcotic. The action of opium, on
the other hand, though more potent, is more uncertain, and more
apt to be injurious. It exerts unquestionably in many persons a
stimulating power, at least when given in moderate doses, and in
the early period of its action. Thus it comes to pass that if the
cerebral tissue be highly hypergesthetic, opium, unless given in large
doses, is apt to produce an effect the very reverse of sedative. It
seems appropriate to cases where there is some but not profound
debility, where the cause of the insomnia consists in some peripheral
nerve irritation, where the brain is not highly hypersesthetic, where
the secretions are tolerably free, and generally where there exists

SLEEPLESSNESS. 179

any grave and severely distressing affection. When given to obviate
sleeplessness of cerebral origin it should be administered in a suffi-
cient dose some time before the period when it is desired, that its
soporific action should be manifested. I quite agree with Dr. Graves
as to the advantage of using it in the form of enema in many in-
stances, and, as Dupuytren held, the dose need not exceed that which
is given by the mouth. The administration of high doses of opium
is one of the most delicate points of practice, and though in skilful
hands it gives often excellent results, had better be avoided if pos-
sible. The previous use of antimony, of a cold douche to the head
while the body is immersed in a warm bath, or of the latter alone
may render a smaller and safer dose of opium equally efficacious
with a larger. The symptom which would most warrant the exhi-
bition of large doses of opium is severe pain provided at the same
time there were no indications of failure of pulse. Large doses of
henbane, as gr. xx of the extract, may in many cases advantageously
replace opium. I have recently given for several nights gr. xxv
to a man on the verge of delirium tremens and sleepless previously
even with morph. mur. gr. ^. When sleeplessness depends on some
frequently-recurring irritation, as cough, much smaller doses of
opium may be sufficient, and they may be repeated according to
need. In maniacal excitement, as Dr. M'Leod'" has recently pointed
out hydrocyanic acid in "Iv doses, frequently repeated if necessary,
is often effectual in inducing sleep.

Forbes Winslow says " a warm bath a short period before retire-
ing to rest, bathing the head at the same time with cold water, par-
ticularly if the scalp be unnaturally hot, will often insure a quiet
and composed night, when no description of sedative, however
potent its character and dose, would influence the system." {Led.
on Insanity, p. 73.)

In the foregoing remarks the nature and causes of drowsiness,
which we meet with occasionally as an independent affection, have
been incidentally noticed. In the great majority of cases it depends
on cerebral debility or exhaustion, but in some I am pretty certain
it is one of the results of angemia of the hemispheres. In these
cases I believe it may be materially lessened, if not cured, by the
administration of belladonna with the view of procuring relaxation
of the arteries. In one instance, where drowsiness came on so
much about 5 P.M. every day that the man was unable to go on
with his work, I gave atropia gr. y^^ in infusion of valerian ter die
with a curativ^e result. In another instance, however, the drug
failed. On the other hand I do not deny that drowsiness may be
associated with cerebral hypergemia, but this is almost invariably
of a more or less venous character. I doubt how far an active cere-
bral circulation ever coincides with drowsiness, except of course in
cases of actual organic mischief. When drowsiness depends on

» "Med. T. and Gaz ," March 14th, 21st, 1863.

180 SLEEPLESSNESS.

cerebral exhaustion strychnia may be resorted to in aid, and only
in aid, of the natural restoratives. It is never wise to goad a feeble
organ beyond its strength.

No. 82.— F. W., set. 22, clerk, ad. March 22d, ill nearly one year. Of
strong make. His face, the cheeks especially, are flushed and of a deep red,
and hot. He finds benefit from dipping his head into cold water. Com-
plains that he has shocks in his system as he walks about, drops on his
knees, at home is continually falling asleep, even in the streets he has fallen
asleep while walking and tumbled against the railings. Is comfortable after
6 P.M., is as strong as ever, but till then from 11 AM. has great debility
and drowsiness. G-ets worse if he walks much or is startled. Has a great
appetite. Had fits when a child. Never passed worms. Bowels open.
Never had ague. Flushes more in face after meals. When the drowsiness
comes on he begins to wander and talk at random. He remained under
treatment till the end of May and improved very decidedly. The state of
the face did not alter much. He took strychnia gradually increased up to
gr. y^2 ter die, besides quinine and iron. These remedies were certainly
beneficial, which puts it, I think, out of the question that the drowsiness
depended on cerebral hypersemia. Tonics would surely have aggravated
the results of such disorder. On the other hand there were marked indi-
cations of cerebral debility, and the state of the circulation in the face may
be ascribed to paresis of the nerves of the arteries. I have notes of a quite
similar case (externally) where there were no cerebral symptoms, only
debility ; tonics were beneficial. These cases give us the practical hint not
to conclude too hastily from the outside to the state of the inside.

Soporose affections are stated by Schramm' to be of very frequent
occurrence in the malarious district where he practises, especially
in children. In them they are usually not serious, but in persons
advanced in life they sometimes prove fatal. The sopor depends in
some instances on cerebral anaemia, in others probably on a direct
action of the poison on the brain. The following case has lately
occurred to me.

No. 83. — E. L., aet. 7, f., ad. March 21, ill four weeks. Her mother
states that she is sick three or four times a day, brings up a little froth ;
after the retching she sleeps for four or five hours, and then is very deaf
for two or three more. She sleeps well, but wakes up with dry throat in
the morning. No tenderness of the epigastrium. Has lost much flesh last
fourteen days. I gave her ferr. et quin. citrat. gr. vi tei- die and ol. morrh.
5i ter die. In about three weeks all the symptoms had disappeared. In
two of Schramm's cases a paroxysmal gastric neuralgia was replaced by a
profound sopor. In a gentleman lately under my care, sufl'ering with great
exhaustion of nervous power and occasional neuralgia, extreme drowsiness
was a marked symptom. In all cases of this kind where we have no reason
to suspect narcotic poisoning, intracranial extravasation, or the like, we
should look to the state of the urine, as latent renal degeneration might be
a very possible cause of sopor.

' Bayer, Arztl. Intell. Bl. 38, 39, 40 ; 1861.

FACIAL NEURALGIA. 181

CHAPTER XX.

FACIAL NEURALGIA.

There are several varieties of this form of affection, which it is
practically important to distinguish. One is the sympathetic, or
reflected, where the pain depends on some cause of irritation seated
in a more or less remote part ; it may be a decayed tooth, and over-
acid stomach, a gravid uterus, intestinal accumulations. Another
is where the pain is produced by some organic central disease, as
in Romberg's well-recorded case. A third is where the pain is
associated with marked tenderness ; and where, judging from the
" juvantia," we must consider the nervous disorder to be of a differ-
ent kind to that which exists in other cases. It is clear that the
conditions cannot be identical in cases which are cured by aconitine
ointment, and those which yield to tonics. Fourthly, there are the
instances which often are evidently produced by the special miasm
which gives rise to ague, and which when their causation is not so
evident are still attended with similar states of nerve debility, and
are cured by the same means. These cases are sometimes markedly
paroxysmal, sometimes show no periodicity. They are of very fre-
quent occurrence in malarious districts ; Schramm observed 195 in
the course of four years at Bodenwohr in the Palatinate. A transi-
tion between the two last varieties is exhibited in those cases re-
ferred to, by Watson and Brodie, in which after the pain has existed
a long while the affected skin becomes swollen, red, and exquisitely
tender. In these it is reasonable to suppose that the paretic state
of the cerebro-spinal nerves has extended to the adjacent vaso-motor,
in consequence of which the skin becomes highly injected with blood,
and its sensory function is consequently exalted. Romberg terms
the condition where the painful part is quite tolerant of pressure
" ansesthesia dolorosa," which he regards as quite distinct from tic
douloureux. Even in the fourth variety, however, there are many
instances in which there is great tenderness of the skin without any
vascular injection.

With regard to the first form of facial neuralgia, I have chiefly
to mention that while we should always have an eye to its possible
existence, and be on the lookout for any indication of remote irri-
tation on which it may depend, we should not be in the case of sus-
pected teeth over-hasty to have them removed. It has occurred to
me more than once to relieve effectually by medicine neuralgic pain
on account of which several teeth had been fruitlessly extracted ;
and on the other hand, the presence of numerous decayed stumps

182 FACIAL NEURALGIA.

in the jaws has not prevented my curing a distracting neuralgia of
the face and head. Dr. Brinton well remarks/ " There are plenty of
facts which suggest that lesions of nerves not necessarily painful
may become so from causes originally by no means local. Thus I
believe there are hundreds of people walking about London this
minute, the diseased nerves of whose carious teeth would be speedily
roused into severe neuralgia by two or three nights of sleepless
watching, and anxiety, or by two or three days of insufficient nour-
ishment, or of violent and exhausting exertion of mind or body.
And conversely I am sure that a generous diet will often relieve the
agony arising from sheer involvement of nerves in a cancerous de-
posit." The case related by Sir B. Brodie where a pain in one foot
was immediately relieved by dilatation of a stricture of the urethra,
which the patient had not even mentioned at first, affords a good
example how latent and remote the real causa mali may be in all
cases of neuralgia, and how carefully we should search for indica-
tions of it. Friedberg records^ four cases of severe pain of the face,
involving in three all the divisions of the fifth nerve, and refractory
to all internal treatment, which at length yielded to the extraction
of one carious tooth. The remarkable circumstance was that other
carious teeth had previously been extracted without relief, though
they were painful and aching, while the tooth which appeared to be
the cause of the neuralgia was painless. I would say generally that
in all cases where the general health and strength did not appear
much impaired, I should think it very necessary to make particular
inquiry after possible determining causes of the neuralgia.

Oppenheimer^ relates two cases of neuralgia of the fifth pair
which obstinately resisted all treatment until the condition of the
nasal cavities was investigated. In the first case a male, set. 20,
had regular paroxysms affecting all the divisions of the right nerve,
which were cured by removing a nasal polypus that was accidentally
discovered. In the second case there were very frequent and irregu-
lar attacks of ill-defined pains, which were materially relieved by
zinc injections into the nasal cavities. These were not, however,
adequate to curing completely the catarrh, which persisted along
with the pains to some extent.

With regard to facial neuralgia depending on central alterations
of structure, I do not know how it is to be diagnosed unless there are
existing symptoms of sucli disease, as paralysis of some limb or group
of muscles. Inefficiency of all remedies would of course make it
highly probable that some organic alteration was at the bottom of
the mischief. It is, however, worth remarking that even in such
cases remedies may produce a certain amount of benefit. Thus in
Romberg's case, sesquioxide of iron and assafoetida at first proved

1 " Lancet," April 11th, 1863.

2 Canstatt's "Jahresb.," 1860, p. 25, voL iii.
Schmidt's "Jahrb.," vol cviii. p. 178.

FACIAL NEURALGIA. . 183

very serviceable. In the cuse of a fem-ile' who had long suffered
from intense pain in the balls of the toes, depending, as the result
proved, on a bony tumour in the internal popliteal nerve, relief was
always derived from arsenic, though it was transient.

The third form must, I think, be rare ; I have scarcely met with a
marked example of it, though analogous hyperaesthesias in other
situations are not uncommon. A typical case of this affection
would, I think, occur in a person of tolerably good health and strength
in whom tonics did not appear indicated. Such a one Mr. Skey's
patient seems to have been whom he treated in St. Bartholomew's
with aconitine ointment. He describes him as a fisherman, set. 40,
of dark, swarthy complexion, apparently of healthy constitution, and
not intemperate, (V. Med. Crazette, vol. xix. p. 158.) It is proba-
bly in cases of this class that two remedies which have been highly
recommended for their occasional success may be expected to prove
beneficial. I allude to muriate of ammonia, and croton oil. Mr.
Skey found the former of more benefit in Mr. Spey's case than any
other internal medicine, though the good effect soon failed. Barra-
lier recommends it to be given during the paroxysm at half-hour
intervals. Besides the temporary relief it was observed that in
cases of headache returning in periodical paroxysms several times a
month the intervals gradually became longer, the attacks diminished
in intensity, and ended by disappearing completely after having
been several times arrested by the remedy. It has proved effectual
in idiopathic hemicrania, in headache consequent on recurring ague,
in those occurring in the decline of low fevers, and in the period of
irritation in typhus. (V. Edin. Med. Journal^ ^ug. 1859.) It is a
remedy which would certainly not avail in cases suitable for quinine
and iron. My chief acquaintance with it is as a remedy for muscular
rheumatism. I have found it useful in one case of abdominal neu-
ralgia, but my experience of it as an antineuralgic is very limited.
With regard to croton oil our knowledge is purely empirical ; we
know that it has achieved great results in a few cases, but we have
scarce any indications to guide us as to the state of system to which
it is appropriate. A priori we may suppose that constipation, and
an absence of prostration would be prominent features of cases where
it was to benefit.

The following case belongs rather to the transitional instances
above alluded to, than to this form.

No. 84. — J. R., ad. July 25th. Ill two months, worse last three weeks.
Has pain from his chin to the top of his head, mostly towards right side.
Is obliged to get up at night, sometimes thrice, and bathe his head with
cold water to relieve the pain. Sweats very much at night. Feels very
low, so as to be unable to work at times at his trade (shoemaking). Pulse
large, very compressible. B. open. T. clean and red. Never had agae,
or lived in the way of it. The pain is sometimes relieved by pressure, at

' V. Lancet, Aug. 11, 1860.

184 FACIAL NEURALGIA.

others increased. He was almost free from pain in a week after treatment
was commenced, but he was still weak when he ceased attendance Sept.
4th. In about eighteen months he came under my care again with the
same disorder. He mentioned now that his head felt hot ; he could hardly
bear to lay it on the pillow, it was so sore. After a fit of pain he trembled
all over. He had six decayed teeth, but felt no inconvenience from them,
except perhaps that he could not drink hot liquids. He ceased attendance
much relieved in five weeks. In about two years he was again under my
hands with the same symptoms, great soreness of the head, and inability to
take hot ingesta into his mouth. He was quite cured in five weeks, and
I have not seen him since (three years ago). His treatment consisted of
quinine and iron, arsenic and belladonna. The latter seemed perhaps even
more efficacious than the former. This man had very much of the stamp
of aguish disorder upon him, as marked by great general debility, nocturnal
sweatings and "cold shivers" which at one time succeeded each fit of pain.
The cutaneous hyperaesthesia was well marked, but it yielded to the same
remedies which subdued the pain. The presence of the decayed teeth did
not prevent the final cure. The relapsing tendency of the disorder was
very marked.

The last form is certainly far the most frequent, and corresponds
with the most frequent forms of neuralgia in other localities.
Schramm^ finds the disorder to prevail much more in the female
than in the male sex in the proportion of 186 to 69. In the former
the disease increased in frequency up to the 30th year, in the latter
up to the 40th. More cases occurred in the first than in the last
six months of the year, 72 from January to April out of 195. The
kind of pain varied very much ; it was often attended with indica-
tions of vasomotor paresis, injection of the eyes, redness and swell-
ing of the skin, lachrymation and salivation. Most cases were
apyretic, but in several there was shivering and fever, or shivering
and sweating. Sometimes the neuralgia suddenly replaced a pneu-
monia, or a gastro-enteritis, or other inflammation. Supra-orbital
neuralgia was always very obstinate. Arsenic was found an invalu-
able remedy in such cases, and where there was a tendency to
relapse. It also appeared to be a specific in chronic inflammation
of the eyes and of the lids. The treatment of this kind of facial
neuralgia, and of similar in any part, may be thus formulated.
Either quinine is to be given in full rapidly repeated doses until
deafness is produced, and afterwards in smaller doses : or, arsenic
in doses of gr. o'o dissolved in distilled water by heat is to be taken
ter die, and extr. belladon. in doses of gr. ^-gr. 1 2dis horis until
either the pain yields, or disorder of vision and dryness of throat
ensue. Both of these modes of treatment are thoroughly efficacious,
but it is of little use in severe cases to adopt half measures.

Rheumatic neuralgia of the face rarely, I think, corresponds to the
course and distribution of the divisions of the fifth, but is more
purely a peripheral aff"ection. The following case seems to illus-
trate this.

' Schmidt's "Jalirb.," vol. ciii. p. 177.

FACIAL NEURALGIA. 185

No. 85. — A returned Indian officer, set. 65, came under my care on
account of some diffused swelling and redness of the nose and left eye. The
nose had a bulbous appearance. He has never had gout, nor had any of
his family. The affection was of three or four days' duration. He took
pot. iod. + pot. bicarb. + ammon. carb., and in six days the disorder had
ceased, but the previous night he had a good deal of pain in the left jaw
and teeth. This was doubtless a rheumatic neuralgia, as the original
affection had been a rheumatic inflammation.

The following case is a good illustration of the fourth kind, I
am indebted for the report of it to my friend Mr. Smith, of John-
street, under whose able care the patient was.

No. 86. — Mrs. S., set. 39, mother of seven children, the last born nine
years ago; she has never been pregnant since till last autumn (1856), when
she miscarried at the second month. Is very stout and leucophlegmatic,
circulation languid; left eye often somewhat everted, especially when she
is weak and tired. Is hardly ever free from pain in the head. Comes of
a nervous family ; one sister, ast. 42, has never menstruated, and has now
mental delusions; another has been epileptic for sixteen years, and is hysteri-
cal in the highest degree ; a third is subject to neuralgia, and has a east in
one eye; a brother is also neuralgic. Mrs. S. suffered at Hampstead,
where she had been living several years, about fifteen years ago, a fearful
attack of " tic douloureux" for weeks, and was only cured by Dr. Elliotson
giving gr. xx doses of quinine till she was quite deaf; she was then quite
cured. She has had slight attacks since, one rather severe at Marlow eight
years ago. After miscarrying last autumn went to Scarborough for two
months and got pretty well. Nov. 10th, 1856. Has neuralgia of left side
of face, principally in the situation of the mental nerve, of moderate severity.
Quinine was given at first in rather small, subsequently as the paroxysms
became more severe and of longer duration, in larger doses until 48 grains
were given in the twenty-four hours, when she became quite deaf, and the
pain quite ceased (15th). The day before she was delirious and suffering
fearful pain. This evening at the usual hour of paroxysm she had shiver-
ing, but no pain. For two hours there ensued an attack of hysteria with
partial syncope, only relieved by stimulants in large doses. 18th. For the
last three nights has had similar attacks coming on at precisely the same
hour with shivering, but gradually decreasing in severity. The amount of
quinine has been diminished ; she takes 10 or 12 grains in twenty-four
hours with as many drops of liquor arsenicalis. 22d. Hysterical attacks
quite gone, slight pain in the face. She slowly gained strength, went to
Brighton, and improved, but had still in spite of quinine slight returns of
the disorder. Towards the end of the succeeding January she had neural-
gia again in the same part, not paroxysmal, and not attended with shivering,
but with some numbness extending down the right arm. The attack yielded
to 24 grains of quinine in the day. Various external applications were
tried, as opium, chloroform, belladonna, Fleming's tincture of aconite, Mor-
son's aconitine ointment, but none of them afforded so much relief as poppy
fomentation applied almost boiling hot. Remarks. — There are several
points well worthy of notice in this highly interesting case. (1) The liability
of the patient by original constitution to derangement of the nervous system,
and the affinity clearly indicated between neuralgia, epilepsy, insanity, and
hysteria, all varieties of dynamic disorder. (2) The resemblance of the

186 FACIAL NEURALGIA.

affection in many respects to disease of malarious origin ; this resemblance
depending, I believe, on the circumstance that the same structures are the
seat of morbid action in both cases. Nerve debility, however produced, easily
generates neuralgia. (3) The hysterical attacks which ensued as the neu-
ralgia ceased were evidently a part of the same disorder, and were subdued
by a continuance of the same treatment. They were surely as much a
physical disorder as the neuralgia itself. (4) The involvement of the hemi-
spheres in the morbid action when it was at its height, and the cessation of
both pain and delirium under the same remedy. The nerve and the nervous
centre suffered alike, but expressed that suffering differently. (5) The evi-
dence the case affords, by the subsequent recurrences at intervals after the
first attack, that the remedy which proved so serviceable did not remove or
destroy the cause of the disease, but simply rendered the system more capa-
ble of withstanding it. The long periods during which she was free from
disease prove, I think, that it was not dependent on any structural lesion.

I have lately treated in a similar way a female, set. 33, who had
been suffering with facial neuralgia six months, and had taken qui-
nine under medical advice without benefit. The pain occurred
about twice a day in paroxysms of such severity that she became
quite beside herself. She found that stooping forward, so as to pro-
mote the flow of blood into the head, relieved the pain. The pain
was speedily arrested by quinine gr. v %iis lioris till her ears were
buzzing. Other tonics were given afterwards and the improvement
has been maintained. She attributed the attack to sleeping in a
damp bedstead, but she had also suffered much mentally, which was
probably the more efficient cause.

The following case illustrates the efficacy of the other mode of
treatment alluded to.

No. 87. — H. W., set. 4-5, m., ad. under Dr. Markham's care Feb. 9th.
He was suffering severely, and was very much relieved by iron and quinine,
and a liniment of chloroform + aconite. His symptoms relapsed after re-
suming work at shoemaking. Dr. Markhara kindly transferred him to my
care Feb. 29th. His history was that he had been ill quite five months,
with pain in face and head ; he had some decayed teeth removed from left
upper jaw, after which an abscess formed, but this is now quite well. The
pain before the teeth were removed was toothache, not like the present,
which he says is frightful, and worse than it has yet been. The pain is
paroxysmal, it comes on the last three days about noon, and gets to its acme
about 1 P. M., subsides about 5 or 6 P. M. It used to be very severe at
night, but is not now. The pain affects both temples and all the top of
head, is attended with a sense of opening and shutting, and with great sore-
ness. The skin of the forehead is not more than just warm, not flushed or
injected, but feels very tender. No pain now in eating. He feels very
weak. Is not gouty, nor were either of his parents. Never in the way of
ague. T. quite clean. P. feeble. B. open. Urine has been very thick.
Pupils of medium size or rather small. No blue line on gums. Quin-
disulph. gr. v atiis huris. Ferri carb. saccht. gr. xx ter die. March 3d.
Head not at ail relieved ', pain seems to shoot through the brain. P. ex.
tremely feeble. Has not been made deaf. Acidi arseniosi gr. ^'o- Aquae

FACIAL NEUUALGIA. 187

distill. 5ss ter die. Estr. bellad. gr. i '2dU lion's, olei morrh. Jij f^^ <^ie.
7th. Was almost quite free from pain yesterday, not quite so well to-day;
has taken about twenty of the belladonna pills, three yesterday ; pupils not
at all large, eyes very photophobic. March 21st. Is muc'h better, has
scarcely any pain at all in head now, has gained flesh, but still feels weak
on exertion ; has worked three or four hours a day. Is a great deal stronger
and better than he has yet been ; has not taken any belladonna for some
time. 28th. Head quite free from pain ; can't sleep at night for pain in
anns if he works, but has no pain if he does not.

Division of the suffering nerve is a remedy wliicli seems to have
succeeded in a few instances, but has failed in many more. It can
of course be useful only in peiipheral neuralgia, and I should think
in states of system when the* general nervous power was not materi-
ally depressed. The nearer to the point of exit of the nerves from
the cranium the section is made the more likely the operation will
be to prove beneficial, but it will be also much more severe. It is
not to be thought of until all other means have failed. J. Kiihn'
records an instance in which the inferior dental nerve was divided
with apparent success, no relapse having ensued during six months
at least. Ch. Frank^ records five cases, in four of which the opera-
tion was successful. In the first, the second and third divisions of
the fifth were the seat of disease. The infra-orbital neuralgia was
cured by division of the nerve at its exit from the foramen, and the
mental by section of the inferior dental nerve before its entrance into
the canal. In two other cases the infra- orbital nerve was successfully
divided. In a fourth the supra- orbital and frontal nerves were di-
vided with good results. In the fifth case the inferior dental nerve
was twice divided, at an interval of above four months between
the operations, but the result seems not to have been satisfactory.
Bratsch' gives the histories of nine patients, all of whom, except
one, at the time of the report were freed from their sufferings. In
several, however, the operation had been so recently performed
that it was by no means certain that a relapse would not ensue,
which indeed seems not impossible, seeing that the nine patients
had shared no less than twenty-five operations among them, nearly
three a-piece. Eisenmann remarks that these cases support the
view that idiopathic neuralgias are of central origin, and agrees in
the opinion attributed to Sir C. Bell that it is not the division of the
nerve, but the operation, and its influence on the nervous centres,
which removes the pain temporarily or permanently.

Trousseau distinguishes epileptiform neuralgia, as he terms it, from
ordinary facial neuralgia. The former is characterized by sudden
violent darts of pain, attended in some instances with rapid convul-
sive movements of the facial muscles, lasting about a minute, but
returning ten to hundred times a day, with longer or shorter periods

1 " Archiv. Phys. Heilk ," iii. 1859, p. 226.

2 Schmidt's ".Jahrb.," vol. ci. p. 293.

3 Canst. " Jahresb." 1S60, p. 25.

18(5 FACIAL PARALYSIS.

of exemption, varying in duration from days to months. The attacks
are induced sometimes by any movement of the face, as in speaking,
drinking, or eating. The suffering is terrible. No treatment cures
effectually, but very large and repeated doses of opium procure,
as long as they are continued, great mitigation of suffering, or
even complete exemption. When the drug, however, is omitted,
the disorder soon returns. Section of the trunk of the nerve also
affords great temporary relief, lasting for days or even months, but
the disorder recurs obstinately. Quinine is of no avail.

HAPTEE XXI.

FACIAL PARALYSIS.

The plan of my work excludes from notice under this head all
cases depending on organic lesion. Inorganic paralysis in this situ-
ation has long been known, and designated as rheumatic. Trous-
seau' says that the action of cold is one of its most frequent causes ;
it surprises those whom it affects in the midst of most perfect health,
and produces no derangement of the economy. A mere current of
air, remaining in a damp place, as in a house whose walls are not
well dried, is enough to give rise to it. Other causes are violent
emotions, as terror, of which he gives an instance, anger, grief.
Sometimes it comes on without apparent cause. Sudden superven-
tion is a pretty constant character of this paralysis. J. Frank states
that seven of his patients were suddenly attacked with this paralytic
affection on putting their heads out of the window in the morning
when it was very cold, though only for a moment. Romberg says,
" It is very common for pain and tumefaction, accompanied by febri-
citations, to occur in the affected side of the face after the patient
has caught cold ; these symptoms disappear after a few days, and
the paralysis remains." The facts above cited illustrate and con-
firm, as it seems to me, the views already advanced as to the causation
of paralysis. When the facial nerve is suddenly palsied by a " coup
de vent," it is impossible to suppose that the cold has acted directly
on the nervous filaaients lying well covered with fat and skin. On
the other hand it is certain that the sensory nerves of the skin must
be affected, and they produce the paralysis by a reflex inhibitory in-
fluence. When the affection results from excessive emotions, such
as terror whose enfeebling effect is notorious, there must be a direct
paresis of the nerve-cells at the origin of the facial, unless we assume
with Brown-Sequard that a spasm of the minute vessels takes place

» "Clin. Med," vol. ii, p. 286.

FACIAL PARALYSIS. 189

in this situation. The occurrence of quasi-inflammatory swelling in
the afl"ected side of the face I should refer to a paralysis of vaso-
motor nerves inducing hypersemia of the part. The paralysis in
rare instances affects both sides of the face. (I am still confining
myself to non-organic affection.) Dr. Gairdner relates^ and com-
ments very instructively upon a case, which was entirely of eccen-
tric origin. All facial expression is completely lost, and labial
articulation also. According to M. Davaine, if the branches of the
nerve given off before its exit from the stylo-mastoid foramen are
paralyzed, there is also dysphagia, a nasal twang of voice, and im-
pairment of lingual articulation. In the double paralysis the mouth
is not drawn to one side, as it often is in the single. The diagnosis
of inorganic from organic facial paralysis is a point of much import-
ance. Romberg asserts that they are often confounded. Trousseau
admits it possible that a facial paralysis, having all the characters of
the disorder we are considering, may result from a very limited
hemorrhage in the mesocephale ; though he adds that in all his prac-
tice he has never met with such a case. He grounds his admission
on Vulpian's experiments, who produced facial paralysis in a dog by
a small wound of the fourth ventricle. The distinguishing signs
which Trousseau confides in are the possibility of closing the lids in
all cases of facial paralysis from cerebral disease, and the retention
of the electric excitability of the muscles, which is lost in the func-
tional disorder. In most cases of cerebral disease the facial paraly-
sis will be associated with hemiplegia or other symptoms. If the
facial nerve be involved in disease of the petrous bone, or have re-
ceived traumatic lesion, the nature of the case is generally sufficiently
clear.

If there be any indications of inflammatory action in the vicinity
of the parotid gland, we may apply a few leeches and purge. If, as
usually happens, there are none, the interrupted current should be
passed for fifteen minutes daily along the track of the paralyzed
nerve, and stimulating embrocations should be rubbed on the skin
of the face. Strychnia may be administered internally, or, as Trous-
seau recommends, endermically. In exceptional cases the paralysis
gets well in twelve or twenty-four hours of itself. Some cases,
however, resist all treatment, though there is apparently no organic
lesion. In some cases refractory to other remedies we may employ
the continuous current. Schultz^ has succeeded in curing six cases
of grave facial paralysis by this means. When the paralysis has
been considerable and of long duration, it is apt to be followed, as
in analogous instances, by permanent contracture to a greater or
less extent of one or more of the facial muscles. Here we observe
again the affinity between paralysis and spasm.

I subjoin an illustrative case.

' V. <' Lancet," May 18, 1861.

2 "Wiener. Med. Wochenschr.," No. xxyii.

190 BETINAL HYPERESTHESIA.

No. 88.— J. E. L., set. 22, m., ad. May 11th, ill one week. Has paraly-
sis of the right facial nerve, the eye cannot be closed, and the cheek is
puiFed out in expiration. He can close the mouth, but not so perfectly as
normally. No numbness of skin of face. Hearing of right ear good. The
affection came on quite gradually, after exposure of the right side of the
face to a draught two days before. No pain in head. Some bad teeth, but
none ache. He was faradized once, used linim. terebinth, to the face, and
took strychnia, and was all but quite well in a month. He improved mate-
rially with the liniment and one galvanization in the first three days.

CHAPTER XXII.

RETINAL HYPER.ESTHESIA.

This common affection befalling one of the nerves of special sense
corresponds closely in its essential features with the neuralgise. It
is true that in most of the latter the disorder tends rather to the
production of anaesthesia than of hyperaesthesia, and that we are
not warranted in regarding the pain as a manifestation of the latter
state. Still it is evident that the retinal affection occurs just in
those states of system which are favourable to the production of
neuralgige, that the general tenor of the concomitant symptoms is
indicative of nervous prostration, and that the " juvantia" are pre-
cisely those which avail to cure neuralgia. The term " scrofulous
ophthalmia" commonly applied to the disease is, I cannot but think,
a bad one, as it is not uncommonly met with in children who have
no clearly marked strumous peculiarities, but who are weakly and
cachectic. Very possibly it may be more frequent in strumous than
in non-strumous children, but it certainly is not limited to the for-
mer. It is remarkable that it should prevail so much among children ;
it seems in them to take the place of the manifold sensory neural-
gias which are such a plague to adults. The treatment which I
have found most satisfactory is to apply an aconite lotion to the eye,
and to administer ferri carb., or ferro-citrate of quinine with ol.
morrh. A healthy state of the alimentary canal must of course be
secured by gray powder, &c., if requisite.

The following cases are instructive : —

No. 89. — J. S., set. 10, m., ad. April 7th, with strumous ophthalmia,
and treated with F. + Q- citr., ol. morrh., collyr. bellad. and blisters till
22d, when he was transferred to my care. He had then extreme photopho-
bia, such that he had not opened the left eye for four months ; the right eye
was almost as bad. He kept his hand constantly pressed over the eyes.
He had suffered with the disorder for six years more or less since he had had
hooping-cough. Pulse weak, jerky. T. clean. B. costive. Quinine, -|-
iron, + tr. aconite (the latter in itlvj doses) qualer die, strychnia +

KETINAL HYPERiESTHESIA. 191

iron 4- hydrocyanic acid, ol. morrh., lead lotion, blisters, occasional leeching,
small doses of morphia, gr. ^ ter die, the same with ferri carb., tannin +
opium, emetics, and tr. ferri mur. n\,x Id is horis were given till March of
the following year, when he was nearly well, and remained so, or rather im-
proved still further till May 6th, taking ferri ammon. citr. + ammon. carb.,
-f inf. calumb. He then ceased attendance. Of all the above remedies,
which were pretty fairly tried, there were two which produced signal benefit,
so much as to make it worth while to notice them particularly. The first
was tannin given in doses increased to gr. x ter die, with liq. opii sedat.
n\^v ; under this the eyes almost perfectly recovered, and remained well for
a month ; he was able to face the light well, and was in the open air all day
long. After getting a wetting he relapsed, and the tannin failed to restore
him. For a month he then took ferri pot. tart, and ol. morrh., but with
no gain. I then gave the tr. fer. mur. itl x, 2dis horis, determined to see
what a "coup sur coup" treatment would accomplish. In fourteen days he
was able to bear the light quite well, and during the remainder of the time
he was under observation (three months) no relapse occurred. I have no
wish to exaggerate the efiicacy of these remedies, and have no expectation
that liberal tanning and ironing of the system will always or often be requi-
site. I should generally expect more good effect from a pure bracing air.
Still I think the above example may be worth remembering in dealing with
obstinate cases. The amount and frequency of the dose of a remedy are
most important items for consideration, and are often by no means suffi-
ciently regarded. Treatment may entirely fail from this cause alone.

No. 90.— x'^. A., f, set. 10, ad. July 26, 1860. Had measles in April;
has been ailing ever since. Skin cold. P. weak. Extreme photophobia
of both eyes, the lids red externally, much lachrymation. T. clean. Appe-
tite indifferent. B. open. Tr. ferri mur. with acid, hydrocy. dil., the
same with morph muriat. gr. |- (er die, powdered bark and soda, tannin +
opium, tannin, colchicum + henbane, belladonna alone, and with iron, ol.
morrh., tr. ferri mur., 2dis horis, continued till Feb. 18th, 1861, failed to
do any good ; the photophobia was as extreme as possible, and there was
very extensive redness and excoriation around both eyes from the constant
irritation of the discharge. She now began to take ferri ammonio-citrat.
gr. V + ammon. carb. gr. ij -f tr. nucis vom. rTLV + inf. calumb. ^i
quaier die, which she continued till July 8th, when the eyes were quite
well, except a slight film of opacity on the cornea. She improved steadily
from the time of commencing this medicine. She was seen again Nov. 21st,
the eyes continued well, she had been in the country. These two cases
were as nearly as possible exactly alike, save the difference of sex, yet the
remedies which had availed most in the first were useless in the second.
It seems to me that such experience as I have just recorded, which of course
is frequently paralleled, affords us some valuable guidance in dealing with
other disorders whose nature is more obscure, as epileptic affections, or other
neuroses. It seems as if, though the kind of remedy is clearly indicated,
it is a matter of exceeding difficulty to find that which shall be exactly
appropriate to the particular instance. Not only so, but the amount of
dose is a matter of material moment. I have seen a sixteenth of a grain of
strychnia ter die cause considerable stomach disturbance, while one-twentieth
was well borne and cured. Where nervous tissue acquires an extreme sus-
ceptibility it is no easy matter to adjust a remedy so as to tone and calm
without injuriously exciting — and this is what is wanted. If these points

192 RETINAL HYPERESTHESIA.

were well considered, we should have fewer sceptics with regard to the
virtue of remedies. In a third case the patient, a female set. 23, of marked
strumous diathesis, all whose family were consumptive, was treated for
more than eighteen months with a great variety of remedies, iron + quinine,
strychnia, hark + soda, tannin, colchicum in full doses, aconite, tr. ferri
mur. rtLx, Stis horis, with occasional blisters, leeches, and various sedative
collyria, but without permanent relief; — even two or three months of coun-
try air failed. She was then admitted into the Charing Cross Hospital,
where she took bark and iron, and had the eyes repeatedly vaporized with
bisulphide of carbon. This appeared to cure 5 I saw her some good while
after she had left the hospital without any trace of the photophobia, which
had been very great, but with a very opaque right cornea. As her circum-
stances were tolerably good, and she had had the fullest ti'ial of internal
remedies, it seems fair to ascribe the cure rather to the bisulphide than to
the rest and nursing of the hospital.

The following case, though not identical with the foregoing, has
much in common, and is of practical interest.

No. 91. — W. 0., £8t. 38, m., ad. Jane 18th. Suffering with his eyes for
seven months ; for the first three or four he was at Moorfields, during the
rest of the time he has been under the care of an eminent ophthalmic sur-
geon. He had been treated since April 26th with an issue in the temple,
liquor cinchon., bark -(- soda, + colchicum, pot. iod., opii gr. ^ ter die,
ungt. hydr. c. opio, hydr. c. creta gr. iij ter die, besides leeches on three
occasions. He was still, however, in a very suffering state when he came
under my care, had been unable to work at his business, that of a carpenter,
for seven weeks. The right eye could not bear the light, but appeared
healthy. The left eye was in a state of marked conjunctivitis and sclerotitis,
with great lachrymation, the cornea was cloudy and the iris muddy. There
was great intolerance of light, so that he was obliged to hold a kerchief to
the eye, though vision was lost. The globe of this eye was very tender.
He had pain at the forehead and back of head. When lying down he was
easier. Urine natural. B. costive. P. exceedingly weak and soft. T.
quite natural. Appetite good now, has not been so till last three weeks.
Has been a teetotaller last twelve months, used to drink hard before ; I had
the great advantage in treating this case of knowing that the best means
which could be employed had been fully tried, and that by the most skilful
hands. It was therefore clear that it was useless for me to attempt to deal
with it purely as a tissue inflammation. Whatever hope there might be of
success must lie in endeavouring to improve the general condition of the ner-
vous system, which was evidently depressed, and in calming the local hyper-
gesthesia. If this could be accomplished the inflammatory phenomena might
be expected to yield also. I ordered him quinse disulphat. gr. v fe.r die,
and extr. bellad. gr. ^ ter die. In five days he could see a great deal better;
the pupil was less contracted, the iris clearer, the inflammation much reduced,
the pain around the eye much less. He felt very nervous. June 27th.
He was ordered quinine gr. iij + tr. ferri muriat. Jss + spt. seth. chlor.
n\^x ter die, and ten days later ol. morrh. was added. By July 21st he
could see with the left eye every letter of his card, the cornea and iris had
become clear, the photophobia had ceased, he had gained much flesh, and
had been working for several days exposed to a hot sun. By August 21st

THROAT DYSESTHESIA. 193

he was well enough to be discharged, though he had passed through an attack
of diarrhoeal disorder. This case was treated on the principle of having re-
gard to the pathological condition rather than to the local phenomena, and
it may fairly be said that the result was satisfactory. The case proves, if
proof be needed, that some inflammations are dependent upon nerve debility.

Retinal Ansesthesia.

This is a much rarer affection than its converse. It seems, how-
ever, to constitute the disorder termed nyctalopia, which appears to
be chiefly produced by debilitating agencies, and the neurotic charac-
ter of which is further affirmed by its nocturnal occurrence. Rom-
berg mentions cold, scurvy, malaria, self- abuse, and the exclusive
use of coarse vegetable food as ascertained causes. It occurs, accord-
ing to Ruete, in Russia, extensively among the poor in Lent. In an
epidemic referred to by Mackenzie, fatigue and inhabiting small dark
rooms seemed to give rise to the disorder. A residence on board
ship is thought by Dr. Mackenzie to conduce to the disease. A suc-
cession of blisters to the temples is recommended by Bampfield
except in cases depending on scurvy. Cold bathing of the eyes, and
quinine, with good food, will probably be advantageous in most cases

CHAPTER XXIII.

THROAT DYSiESTHESIA.

This affection is a neuralgia differing in no respect essentially
from the same disorder in other parts. It is certainly, at least in
its well-marked forms, of rarer occurrence. From the peculiar sus-
ceptibility of the throat a dyssesthesia of this part produces consider-
able distress. Patients complain of feeling as if they should be
ckoked, and the sense of impending suffocation is sometimes very
urgent, of dysphagia, of a sense of heat, dryness and burning. The
throat on inspection is found either normal, or but slightly inflamed,
and the nervous distress is out of all proportion to the visible alter-
ation, if there is any. The patients are mostly females, but the
affection is quite unconnected with hysteria, in so far as that term
is intended to imply a tendency to simulate or exaggerate disease.
Where a rheumatic element can be discerned, pot. iod. or ammon.
muriat. should be given, generally with bark or ammonia on account
of the existing debility. If the neuralgia appear to be simple, qui-
nine and iron, with ol. morrh., and sometimes arsenic steadily admin-
istered, will effect a cure. For some illustrative cases, I refer to the
13

194 LINGUAL NEURALGIA.

Med. Times and Craz.., May 2, 1863. The following is of tlie same
character.

No. 92. — E. G., f., set. 36, married, ad. Nov. 5tlj, ailing three years, ill
one month. Complains of pain in neck and head, of a sensation of swelling
in throat and tongue ; wakes np at night with palpitation of heart, and a
sense of being very ill, attended with choking. From 8 to 12 P.M. a feel-
ing comes over her as if she could hardly keep life in her ; it seems to pro-
ceed from the left hypochondrium, causes palpitation, and takes away her
speech. Throat is not at all sore. Has no dyspepsia Is weakly. Heart's
action a little excited. When first attacked she was purple all over, and
seemed to be dying ; had then been up three nights nursing. Brandy relieves
her. Ordered F. + Q. citrat. gr. x + tr. nucis vom. Ti^xij + aq. §j ter die,
and subsequently ol. morrh. On this treatment she has improved in a very
marked manner. Dec. 3d, she was better a great deal. Jan. 11th, has
been up at night nursing a sick child ; disorder relapsing. A lady recently
under my care suifered most severely with this disorder ; her distress was so
great she felt as if she should lose her reason. At night she was much
worse ; could get no sleep in spite of several doses of chlorodyne. She had
had the affection on and off for a long time ; when it ceased, which it did at
intervals, she got well immediately. Bromide of ammonium and pot. iodid.
were beneficial.

Dr. L. Tiirck' seems to have noticed this affection, which he desig-
nates as neuralgia and hypereesthesia of the throat. He states that
the pain is increased by continued talking or singing, which I should
think very probable. The treatment he employs consists in resec-
tion of the gustatory nerve and cauterization with solid nitrate of
silver.

CHAPTER XXIV.

LINGUAL NEURALGIA.

This is a very severe and intractable variety of nerve disorder,
at least in bad cases, far more so than the preceding. I have termed
it a neuralgia, and believe that it is such essentially. There is,
however, in well-marked instances more or less of morbid alteration
of the mucous membrane. The surface appears over-red, insuffi-
ciently covered with epithelium, as it were denuded in patches,
between which are others of whity coating. The edges are often
indented, and there may be some appearance of ulceration, but this
is only exceptionally j)resent, and is certainly not of the essence of
the disorder. The distress from the sore or burning sensation is
very great, and the patients are apt to have a morose, unhappy look.
The disorder is remarkably persistent ; in one of my cases it had con-
tinued twelve, and in another six years. Of five cases, three were

1 " Wien. Allg. Med. Zeit.," vii. ix. 1862,

LINGUAL NEURALGIA. 195

females. In the way of treatment iron and quinine, arsenic, ol.
morrhuge, tr. aconite have proved beneficial as internal remedies, and
among these I think arsenic holds the highest place. Locally borax
with glycerine affords some relief. I must acknowledge, however,
that I feel far from confident, when entering on the treatment of a
case of this kind, of achieving any decided success. Milder cases
certainly are cured, but old standing ones are very obstinate. The
cause of this is, I think, partly the high degree in which the organ is
endowed with nervous susceptibility, and partly its almost continual
exposure to causes of irritation. II va sans dire that the state of
which I am speaking is not merely the result of bad and decayed
teeth pressing against the organ. The following cases are worth
recording : —

No. 93.— M. C, f., set. 52, ad. May 26th. Ill one year as at present,
worse the last six weeks. The disorder commenced first six years ago. The
tongue at its anterior third looks red, denuded, eroded somewhat, with thin
white patches on its surface. A sensation of burning rather than soreness
is complained of. P. of good force. Never had any cutaneous eruption.
Lotion of borax and glycerine. Liq. pot. arsenit. ttlIv ter die. June 16th.
Is getting better. T. much easier. 30th, Mouth very painful, burning sen-
sations in throat, slight indications of an eruption on the tongue. July
10th. P. full and rather excited, has burning pain in tongue and throat.
T. has the same appearance as at first. Can't take any food. Quinine gr.
vij ter die. 01. morrh. 3i ^f^r die. 24th. Is a great deal easier, has none
of the burning heat now. T. more comfortable, but feels parched at night.
Takes food better. Aug. 4th. Doing well. T. looks healthier, more covered
with epithelium. 18th. T. a great deal better, only a little place at left side
which is sore. Pt. Ferri carb. saccht, gr. 20 ter die. 28th. T. very pain-
ful last four days. Pt. She did not attend again ; probably the relapse was
not of long duration, but it marks well the obstinate character of the dis-
order.

No. 94.— M. S., f , get. 30, ad. Deer. 16th, 1861. A large, finedooking
woman, unnaturally flushed in cheeks, at present they are hot. Skin of
hands cool, damp P. quick, weak. Is weakly, suckling nine months.
Has headache and loses her sight at times. Has five healthy children, two
dead with measles, and one with teething convulsions. She has been ill
for twelve years, suffering with her tongue ; it feels sore along the edges,
which are indented, but not ulcerated. Some weeks later, when she was
suifering much, it was noted that there were small streaks or spots of red
elevated papillse, where the mucous membrane appeared denuded ; in the
intervals the surface was pale and depressed. The tip was the tenderest
part. Teeth pretty sound. Digestion often imperfect. Manner morose.
Urine very clear and pale, sp. gr. 1010, deposits only scaly epithelium. T.
is much better some days than others. Tlie affection has been regarded as
syphilitic ; she has taken hyd. bichl. and pot. iod. and pot. chloras, without
benefit. She never had any cutaneous eruption. Treatment was continued,
though not regularly, up to July 28th, 1862. She benefited more by liq.
potas. arsen. ttlvIj — x ter die, but at the time of her taking this she became
pregnant, which induced, as it had on several previous occasions, stomach
derangement, and aggravated the lingual disease. I saw her again Feb.

196 LINGUAL NEURALGIA.

6th, 1863, when she had been confined fourteen days. She stated that she
had suffered much with her T. all through her pregnancy, but was relieved
soon after. This is the only pregnancy where this has been the case ; usu-
ally the neuralgia continues a long time after. She is now again under
treatment.

No. 95. — J. Gr., m., ast. 33, ad. March 19th. Ill two years with tongue
affection. Some spots form on one or other margin and under surface,
which appear slightly depressed, and partially covered with a whity layer,
detached epithelium. These were seen on several occasions during the time
he remained under observation (about five months) ; they never appeared to be
more than excoriations. He had had a chancre once, but there was no cica-
trix to be seen on the penis. No trace of syphilis. Arsenic with tr. aconite
and ferri + quin. citras was of much benefit, so that on one occasion he
thought himself quite well. He soon, however, relapsed. At the time when
he appeared recovered there were still traces of the whity patches remaining.
In this case more than in any other there were indications of some quasi-
eruptive affection like a vesicular skin disease ; but I doubt whether this
was more than secondary. I think there was more sensory disorder than
the small amount of visible local alteration could account for.

No. 96.— W. W., m., set. 50, ad. July 27th. Ill six months. His
tongue looks at anterior part of dorsum denuded, and semi-raw, with whity
coating here and there, and some tendency to fissure, especially at the tip,
the edges indented. He can scarcely eat anything for the soreness, which
is relieved by hot water, but cold causes smarting. Never had eruption or
sore throat. Had a chancre twelve years ago, and suppurating buboes
thirty years ago ; no cicatrices in groins or on penis. Pain is always worse
at night. About October 1st, when the tongue was feeling quite well, I
observed a characteristic arcuate group of syphilitic tubercles encompassing
the left commissure of the lips. Subsequently this group spread periphe-
rally. Arsenic with cod-liver oil has been of material service to the tongue,
so that it is kept pretty easy as long (Jan. 7th, 1864) as he continues the
remedy, but on two occasions, when pot. iod. and nitric acid have been sub-
stituted, he has immediately relapsed. Painting the eruption on the lips
with iodine has lessened it a good deal. Jan. 25th. The state of the
tongue is aggravated ; there are in the middle of the dorsum two or three
fissure-like depressions with intervening induration ; the surface of the cheek
is red and sore ; he feels very low and languid. The tongue is in more
pain at night. Quinine gr. v + liq. pot. arsenit. Tr^x ter die. Pt. «X3. oleo.
He continued this with decided benefit up to Feb. 15th, when I gave him
besides Plummer's pill gr. v, o. n. March 3d. The eruption of the face
had improved very much, his tongue looked much better and healthier, and
felt to him nearly well ; he could eat anything. The mixture was omitted,
and the oil and pill continued. 10th. Still doing well. It is doubtful in
my mind whether this was a case of actual syphilitic neuralgia, ^. e., depend-
ing principally on the poison of syphilis, or whether it was ordinary neural-
gia occurring in a syphilitic subject. I rather incline to the latter, inasmuch
as pot. iod. was injurious while arsenic was beneficial. The mercurial,
however, has certainly done much good.

No. 97. — E. E,., f , set. 55, had suffered since the spring of 1858 with
more or less of a choking sensation, which at times came on " so fearfully"
that she thought she must be choked. She described her state from this
sensation as not feeling "ill exactly, but out of spirits, and fearful, as I sup-

BRACHIAL NEURALGIA. 197

pose one would feel if a halter were about one's neck." Her tongue was
so very sore that it was painful to eat and difficult to talk. She thought
that the principal seat of the disorder lay in the tongue, which caused con-
stant eflForts to swallow, and that produced the dryness in the throat. Oc-
casionally she was quite free from the distressing dysaesthesia. She took
quinine with decided benefit, as well as a generous diet. In the autumn of
1859 she came under my care again in a state of great depression, with a
cold, pallid skin, very weak pulse, anorexia, nausea, and very distressing
sense of dryness of the mouth, her tongue feeling like a piece of leather.
The night was the only time when she was quite free from the distressing
sensation. Tongue appeared indented, but not ulcerated. Bark + ammo-
nia was given, and acidi arseniosi gr. oV ^^^ '^'*^) ^^^ ^^^ removed to the
seaside. In three weeks she was almost if not quite well. In this case
there appears to have been a combination of lingual and pharyngeal dysses-
thesia. I have considered several times how far the condition of the tongue
described above could be regarded as the result of lichenoid eruption, but
I have never seen any such state of the tongue in ordinary lichen or prurigo,
nor have I seen in lingual neuralgia any such eruption of the cutaneous
surface, nor has the appearance of the tongue itself sufficiently warranted
the supposition. In severe cases of this disorder Dr. L. Tiirck's practice
of dividing the gustatory nerve might, I think, be adopted.

CHAPTER XXV.

BRACHIAL NEURALGIA.

Romberg gives but a short notice of this form of neuralgia ; he
considers it less frequent than crural, and less isolated than sciatic
and facial neuralgia. Lussana and Bergson have entered fully into
the subject in their prize essays published at Milan 1859, 1860, and
reported fully in Schmidt's Jahrh.^ vol. 108, p. 168, and vol. 113, p.
296. Lussana describes at length the various symptoms produced by
neuralgia in the several nerves proceeding from the plexus, noticing
particularly the terminal painful points, the superficial, and the in-
termediate painful track (via dolorosa). The superficial painful points
are where a nerve is given off from its trunk, where it perforates a
muscle, or runs round a cylindrical bone, and where it becomes
subcutaneous. In its direction the pain may be centripetal or cen-
trifugal ; in the latter case it is continuous, and without any elevation
of temperature. The pain is as a rule increased by pressure, and, ex-
cept in the case of the internal cutaneous nerve, by motion. With
regard to the temperature of the affected parts Lussana finds it ob-
jectively or subjectively increased in neuralgias of cutaneous and
sensitive nerves ; objectively or subjectively lowered in neuralgias
of nerves that are chiefly motor. Whenever the affected nerve is

198 BRACHIAL NEURALGIA.

compound, i.e., motor as well as sensory, muscular symptoms are ob-
served, which vary much in degree, but may amount to complete
paralysis. If the short and long thoracic nerves are affected, the
respiration may be short, laborious, and painful. Pyrexia rarely
occurs except in plethoric habits ; nausea and gastric disorder may
be present, or even delirium. The type is generally inter- or sub-
intermittent. The diagnosis between Br. Neuralgia and Neuritis is
made to turn on the greater rarity of neuritis, on the more apparent
causation of the latter, on the absence of pyrexia in neuralgia, on the
more continuous character of the pain in neuritis, on the absence
of signs of local inflammation, and of local tenderness on pressure
of the affected nerve, on the greater amount of pain in the termi-
nal points in neuralgia, and in the trunk in neuritis, on the
greater constancy and earlier appearance of paralysis in neuritis, on
the greater severity of the muscular cramps and spasms, and on the
different state of the terminal points in chronic cases, they being
painful in neuralgia and anaesthetic in neuritis. In neuroma the
pain extends more in a centripetal direction than it does in neural-
gia. Lussana notices the existence of neuralgic pains in disease of
the heart and great vessels, in disease of the lower part of the cer-
vical region of the spinal cord, and of the vertebral column, in hepatic
disease, in constitutional syphilis, and in lead poisoning which might
be mistaken for essential brachial neuralgia.

Bergson arranges brachial neuralgias more according to their
causes, as traumatic, rheumatic, sympathetic, hysteric or chlorotic,
saturnine, such as depend on spinal irritation, and finally the idio-
pathic or essential. He rests the diagnosis of neuritis on the almost
invariable previous occurrence of an injury, and on the increased
size of the painful nerve, which can be detected through the skin.
True chronic idiopathic neuralgia he considers to be very rare, and
very refractory to treatment, while acute is much more tractable.

I have records of seventeen cases in which the nerves of the hand
and arm, especially the median and ulnar, were the seat of more or
less severe neuralgia. As the affection has not been described so
particularly in our own country, it may be worth while to record
them shortly. Fifteen of them were females. The oldest patient
was sixty-six, the youngest twenty.

Case 1, — M. C, aet. 25, f.; ill three months with pain of right hand affect-
ing all the parts supplied by the median nerve. It is worse at night, de-
stroys sleep. After other treatment continued for a month had failed, I gave
quinine gr. v te7' die, and subsequently gr. x ter die. Under this she was
well in three weeks.

Case 2. — H. 0., f., aet. 54 ; ill for a long time with a numb and sleepy
feeling in her hands at times, aggravated to violent pain at night. Cured
in about ten days by small doses of quinine and iron.

Case. 3. — C. B., f , of mid-age; is awoke during night by a numbness or
pain in the fingers of both hands, those supplied by the ulnar nerve being
first affected. The morbid condition extends to the forearm. During the

BRACHIAL NEURALGIA. 199

day the neuralgia ceases. Cured in five or six weeks by moderate doses of
quinine + iron. Slight rigors occurred at night as the neuralgia yielded.

Case 4. — M. J., f., aet. 29, four months pregnant. Ill one month with
pain in hand and forearm not extending above elbow, severe at night, but
felt only as a numb sensation during the day. There was marked debility.
Quinine gr. xv and 5s?s in the day failed, and so did arsenic and ferri carb. ;
quinse gr. ij + ferri sulph. gr. iv ter die, was now given with morphia and
henbane at night, and cured in three weeks.

Case 5. — E. E., f., set. 56, complains of pain in right forearm extending
from fingers up to elbow, commencing in mid-finger. It is of more burning
character at night, does not disturb her rest, but is very severe in morning,
when she cannot move her hand to open or close it. The fingers often feel
burning when she touches or holds anything, at other times are numb.
Foot somewhat similarly affected. Small doses of quinine + iron, larger
doses of quinine, carbonate of iron, muriate of ammonia and cod-liver oil
failed to do more than to give some temporary relief. Under strychinae gr.
Y2 ter die and extr. col. co. gr. v, o. n., with the continued use of ferri carb.
she improved considerably, so that she was able to do needlework, whereas
she had at first been unable to hold a needle. She continued this treatment
five or six weeks, having had for the last fourteen days pot. iod. gr. ij ter die
in addition, and was then well enough to be discharged. One galvanization
appeared to be beneficial, a second rather injurious.

Case 6. — J. M., f., aet. 48, suffers with bleeding haemorrhoids. Ill three
months with pain in centre of right palm extending up the arm over the
shoulder to the spine ; it is constant and gets worse, is increased at night.
Hand is numb except the fingers and thumb; there is much burning sensa-
tion in it. No sleep at night. Cured in a month by small doses of quinine
+ iron, and morphia at night. It was remarkable in this instance how the
pain extended itself upwards like an aura, not in the track of a nerve, and
how the fingers were exempted from the disorder. The affection was evi-
dently peripheral.

Case 7. — E. M., f., set. 47 ; ill three weeks with pain, chiefly of right mid-
finger, in day-time it is numb. Left hand slightly aifected. Urine very
thick. Pot. iod., liq. pot. arsen. and liq. pot. for a week were of no avail,
quinine in gr. xv and xx dose daily was more beneficial, but recovery took
place under quinine + iron + liq. opii sed. in small doses with henbane at
night. Some pruritus pudendi occurred during the last few weeks of treat-
ment, and was much benefited by a borax and opium lotion.

Case 8. — J. T., f., aet. 66. Ill more than six months. Is quite well
except in her arms, which get stiff and numb, and ache, and are very cold.
She suffers thus most at night. She took ferro-citrate of quinine gr x -f-
tr. nucis vomicse ttlx + aq. 5j ter die, and used locally lin. camph. co.
In six weeks she was nearly well.

Case 9. — S. K., f.^ aet. 40. Ill more than a year. Has pains in hands,
extending up arms to shoulders, giddiness and general weakness. Most pain
in right arm. Pain shifts from hands occasionally to the left side. With
pot. iod + citrate of iron and quinine, she recovered in about three months.

Case 10. — E. L., f., aet. 46. Ill fourteen days. Cat. ceased three years.
Some rheumatic symptoms lately. She took at first pot. iod. with alkali
and eolchicum with benefit for a week, her head being relieved; but she
complained of her hands being attacked with numbness and cramp in the
morning about 5 A.M., which continued in fits of ten minutes duration off

200 BRACHIAL NEURALGIA.

and on till noon. A week later the pain came on earlier in the middle of the
night, and was severe. With quinine and iron in moderate doses she im-
proved, but did not recover. Probably rest and good food were essential
as affording a basis for medical treatment. In this respect the disadvan-
tages of external hospital patients can hardly be exaggerated. Success with
them is a real test of the efficacy of drugs.

Case 11.' — E. B., m., set. 65. Ill three or four days. Stout, healthy
looking. Has lost the use of right hand, can hardly grasp at all with it or
use a knife or pen. The parts supplied by the median nerve are numb, but
never in pain. Feels some stiffness up to the elbow. The affection came
on suddenly. No pain in head, no giddiness. Not subject to rheumatism.
Skin warm. Glands in axilla not enlarged. He took for a week hydr. bichl.
gr. } + pot. nitrat. gr. x + inf. gent. co. ^j (er die with slight benefit.
Afterwards he had citrate of iron and quinine gr. 8 ter die., and was well in
a month.

Case 12. — C. G., m., set. 20. Ill one week with pain in left arm, from
elbow to tips of fingers ; worse at night, relieved by heat. With gr. xij of
quinine daily he was quickly well.

Case 13. — C. R., f., aet. 40. Ill three weeks with pains in arms and
hands ; after much exertion her fingers get quite straightened so that she
cannot bend them at all, she then feels " awful" pains in fingers extending
up to shoulders. The pain is a great deal worse at night, is a sort of ting-
ling and numbing pain. Can hardly dress herself in the morning. Left
arm but little affected. Skin warm. Urine pale. Pulse not weak. Small
doses of quinine + iron and pot. iod. were of no avail ; she complained eleven
days after admission, that if she had any hard work during the day her hand
at night got quite stiff, and was in unbearable pain after she had slept about
two hours; while if she had a quiet day she suffered only numbing and tingling
sensations at night. The fingers got numb if she tried to write or sew. She
suffered in exactly the same way eleven or twelve years ago. She was con-
siderably improved by full doses of quinine gr. 20 — 30 in the day. An
interlude of dyspepsia then occurred, after the relief of which she took
ferri carb. gr. 20 te7' die, and was nearly well at her last visit. The effect of
exertion in aggravating the disorder was very apparent in this case.

Case 14. — A. R., f., aet. 43. Ill seven days, was attacked in sleep all
of a sudden, pain came on in the left shoulder, ran down the arm, and set-
tled in the hand, which feels very powerless ; the two inner fingers are much
more numb than the others, but all are much affected. The pain in the
hand keeps her awake at night, being worse then ; it shoots down from the
elbow. Hand sometimes very cold, at others hot, when hot the pain is in-
creased. Urine clear. Aspect pallid. P. weak. The pain quite ceased
under full doses of quinine, gr. xl — 1 a day with ol. morrh., and the numb-
ness also diminished, but the hand remained almost completely paralyzed
with scarcely the least movement of flexion or extension. The quinine alone
seemed only to weaken her memory and sight a little ; when ferri sulph. was
added, she became nearly blind and deaf After this she was ordered strych-
nise gr. 2^^ — ^g- with tr. cinch., under which she regained some motor power,
but in spite of galvanizing both with the interrupted and continuous current
(she wore Pulvermacher's chain for some time) and a month in the country
there was still very little power over the hand, when I last saw her after
three months' treatment.

Case 15. — A. L., f., set. 47; ill at first for six weeks with sore throat

BRACHIAL NEURALGIA. 201

and debility, got much better. At end of three months began to complain
of agonizing pain extending from shoulder to wrist, and to the finger ends,
continuing day and night, destroying all rest, and extending up the side of
neck. No difference in appearance or temperature of affected parts. P. of
good force, rather frequent. Of large make. Feels very weak, but other-
wise well. Quinine in daily dose of gr. 20 to 28 failed to benefit, as well
as extr. belladou. gr. ^ 2dis horis, and liq. pot. arson. n\,v ter die. Pot.
iod. gr. V — vij ier die, with two opiate subcutaneous injections was of some
service, but most benefit was obtained by the local application of tr. aconite
undiluted with arsenic internally, under the use of which the arm became
quite well. Just after this, the aconite having been continued about one
month, and the arsenic five weeks, an eruption appeared on the upper arm
attended with fearful itching and much heat and redness. The aconite was
replaced by a strong lead lotion, and the arsenic continued. Three days
later erysipelas had markedly developed itself over most of the arm and
shoulder, attended with swelling and papular eruption, and pinching and
burning pain in the part. She felt shivery. P. excited and feeble. Bark
and ammonia were ordered, and the arsenic omitted. In four days all the
redness had subsided, the swelling continued with much pain about the arm
of scalding character. Much thirst. In ten to fourteen days she was well.
In this case aconite and arsenic appeared to be the most effectual remedies.
I can scarcely think the aconite had anything to do with producing the
erysipelatoid inflammation, as it had been used fully three weeks without
any such result. I have, however, known aconite to cause cutaneous
irritation. If this cause be put aside, I see no other view to take than that
as the cerebro-spinal nerve disorder yielded the vaso-motor nerves became
implicated, and this in the way of paralysis. There does not seem in this
case to have been any musculo-motor nerve paralysis, which was so marked
in No. 14. In a case I saw only once the patient, a female, aet. 45, suffered
•with nocturnal burning, throbbing, and painful sensation in hands and arms
extending up to the shoulders with numbness of the fingers. The urine
was clear, she had no indigestion.

Case 16. — E. G- , f., set. 26; ill two months ago with scarlet fever, on
making any exertion experiences a pain in chest, and loses sensation and
power in left arm. P. 96, weak. She took strychnia and iron, and was
nearly well in fourteen days.

Case 17.— S H., f., at. 34, ad. May 19th, ill five weeks. Her right
hand " goes dead" three or four times a day, it is constantly weak so that
she cannot hold things with it, and she has constant pain and tenderness at
the styloid process of the radius ; no swelling of the wrist. T. whity and in-
dented. B. costive. Urine rather dark. Has lumbar pain. Is weak and
languid. She was not benefited by small doses of quinine and pot. iod.,
became worse with exceeding pain about the wrist and up the arm ; a blister
had caused much irritation. The hand was so cold one night (May 28th),
that she was obliged to put it for relief into hot water. There was some
diarrhoea and nausea, and she felt extremely depressed and languid. The
quinine was increased to 9i in the day and the bowels quieted with opium
and chloric ether. June 2d. A great deal better ; the other fingers are
comfortable, but she has much pain in the index and thumb. While the
blister was open she was free from pain in the styloid process, now it has
returned to that part, and to the adjacent articulation of the thumb. The
quinine was increased to gr. viij ter die, and by the end of June she was
convalescent and went to the country.

202 BRACHIAL NEURALGIA.

The above histories are sufficient to prove that brachial neuralgia
is not, at least in this country, a very rare affection ; it is rather
curious that unintentionally I have recorded just as many cases of
this disorder as of sciatica. The two seem to be essentially similar
in their nature, relation to rheumatism, causes, and treatment. A
rheumatic element appears, however, to be much less frequent in
brachial than in sciatic neuralgia, and in correspondence with this
pot. iod. and arsenic are found to be less efficacious. The influence
of debility in predisposing to and maintaining the disorder is very
decided. Besides this, however, we must assume some special agent
to be affecting the nervous system injuriously. What that is cannot
be precisely stated, but it seems to me that we shall not err greatly
if we suppose some general miasmatous influence, widely dispersed,
and varying much in its potency at different periods, to be the efficient
motor of the phenomena. There seems to be some sound reason for
believing that neuralgic and epidemic catarrhal (influenzal) disorders
are rather closely correlated in their origin, the cause of the latter
giving rise also to the former. Mr. Norris, of Petherton, and Mr.
Ewens, of Blandford, have recently stated' their experience as to the
occurrence of sequelge of hemicrania, and intermittent cephalalgia in
connection with influenza. Hjaltelin^ says that influenza in Iceland
was followed by various neuralgic pains, especially lumbago, otalgia,
odontalgia, facial and intercostal neuralgia and hemicrania. Similar
observations have been made long ago as already stated by others.
Several points of the above histories illustrate the neuralgic habitudes
of the disorder. The nocturnal aggravation of the pain ; its remission
or absence by day ; the intimate relation between it and numbness so
that the latter seems to be a less degree of the same condition ; the
coexistence in some instances of motor disorder ; the prevalence of
general debility ; the absence of self-limitation are family features
of neuralgia. The results of the treatment above detailed seem to
me to show pretty conclusively that the malady was not depending
on any remote cause of irritation, as decayed teeth, worms, intestinal
accumulations, &c. ; nor on gouty poison or dyspepsia. These, how-
ever, are very possible causes, and we should be prepared to meet with
them. The influence of heart-disease in producing a certain form of
brachial neuralgia should also be remembered. The cases illustrate
sufficiently the treatment which should be pursued. One main point
is to improve the general tone and strength. If this be effectually
accomplished, there will not generally be much more required. Good
air and food, and the usual tonics with occasionally a nightly sedative
are the most reliable means. In some instances ammonia, valerian,
and arnica, with nitrate of silver prove more beneficial than quinine.
In local applications I have not much faith, but they may sometimes,
as in No. 15, afford much benefit. The interrupted current will I
think chiefly be found useful where there is motor paralysis ; I am

' "Med. Times and Gaz.," April 11, 1853.
2 "Edin. Med. Journ.," Feb. 1863.

BRACHIAL NEURALGIA. 203

sure that it should be used cautiously to weak and hyperaesthetic
nerves lest it aggravate rather than relieve the pain, Becquerel,^
however, maintains that an induced current passed through a nerve
in its long axis will always cure neuralgia if the stream is sufficiently
strong, and the intermissions are very rapid. I confess I should
not like to be the patient so treated. With regard to the continuous
current it might, I think, be serviceable as a means of procuring
temporary relief, but it is a very troublesome means to use (I speak
of Pulvermacher's chain), and would be of little real avail unless
the morbid tendency of the general system were amended by tonic
treatment. Dr. Radcliffe has recently praised the use of the hypo-
phosphites in neuralgia, together with cod-liver oil and fatty food,
viewing the disease from a chemical stand-point. I have not found
any special advantage from the hypophosphite of iron and quinine
in a few instances of various disorders in which I have tried it, and
I certainly should not be disposed to rely on the acid alone to the
exclusion of the two bases whose efficacy is so well proved. As an
occasional sedative I am as much disposed to rely on chlorodyne as
on anything else. A patient of mine told me she had cured her-
self with this of a sciatica which had proved refractory to orthodox
medical measures. I must say, I should never use willingly any
preparation whose composition was kept secret. The following his-
tory seems properly to find its place here as it refers certainly to a
peripheral neurosis, and not to a central affection. The disorder
was probably of the same nature as neuralgia, but, inasmuch as it
was located in a mainly muscular nerve, it produced rather paralysis
than pain. There was, however, very marked loss of sensation,
which is often as much a part of neuralgic disorder as pain.

Case 18. — G-. W., ast. 40, ad. Nov. 11th; ill fourteen days. Has lost the
use of his right arm, so that he cannot raise it from the shoulder-joint and
abduct it by the action of the deltoid ; he can move the forearm, but not so
well as the other; has had great pain about the insertion of the deltoid, which
came on in the course of the night, and has been replaced by numbness.
The angesthesia does not extend quite to the elbow. Is not subject to rheu-
matism. Functions generally in good order. Does not feel weak. Works
in a damp place in a brewery. Dec. 20th. Right deltoid much wasted, un-
excitable by galvanic current, skin covering it also very numb; the adjacent
muscles and integuments are quite lively and sensitive. Whichever pole is
applied to the highest part of the arm while the current (interrupted) is
passing he feels the shocks there, not in the lower. But if I place the poles
opposite each other on either side of the deltoid, he feels the shocks in both.
He finds the arm stiifest in cold weather, and he suffers more pain then in
it. The chief pain is a little below the seat of numbness. Jan 7th. Del-
toid much wasted, remains insensible to the strongest current, which has
been used almost daily. On one occasion the current was sent directly
through the muscle by needles passed through the skin. No good effect
ensued, but he was unable to bear nearly so strong a current as before. Ife

' L'Union Med,, Nos. i. and iv., 1861.

204 SCIATICA.

is very observable that the cold air produces "gooseflesh" all over both
upper arms and shoulders when he is stripped, except over the paralyzed
deltoid. Some weeks later the interrupted current had precisely the same
effect, the anaesthetic skin remaining quite smooth, while the sensitive con-
tracted. Feb. 4th. I have passed a continuous current from a 6-cell battery
through needles stuck into the muscle, no muscular motion nor any sensa-
tion was produced while the current was passing, but on interrupting it the
muscle contracted. The deltoid has shrunk and wasted much since I last
saw him. He was now directed to wear a small Pulvermacher's chain on
the affected part. In three weeks there was no improvement ; the deltoid
and infra- spinatus muscles were quite irresponsive to faradization, the skin
over them still numb. March 12th. Slight improvement. April 16th. Is
recovering more use of arm, and the numbness diminishes. By about the
middle of September, up to within a month of which he wore the chain, he
had quite recovered save a little numbness in the skin over the insertion of
the deltoid. Medicine had a fair trial in this case, and appeared ineffectual.
Pot. iod. in gr. v doses ter die, pil. hydr. c. opio to salivation, sulphuret of
potassium baths, strychnia carried up to gr. \ ter die, and ammon. murias
failed to produce decided amelioration.

The strychnia was certainly continued at the rate of gr. -^^ ter die,
during a good part of the time during which he was wearing the
chain, but as it had been fairly tried before without benefit I think
it cannot lay claim to the improvement, which was due either to the
continuous current or to the vis med. natures. The chain is no
favorite with me; it is a troublesome and rather painful remedy, but
I think there is much ground for regarding it as the really effectual
agent in this case. Paralyses such as the one above, described are
much more apt to remain as chronic and incurable affections than
to disappear of themselves. The pathology of the above case is
obscure, the most probable view is that the disorder was essentially
similar to neuralgia of sensory nerves, but it remains unexplained
■why it was so refractory to treatment. It yields, however, in this
respect to Case 14, which was not benefited by the chain, but which
in most respects quite corresponds to the picture of neuralgia. It
is quite possible and probable that in certain cases the molecular
change which conditionates neuralgia may pass on to larger and
more complete alteration, even to organic lesion.

CHAPTER XXVI.

SCIATICA.

Cases. — (1.) G-. N., set. 56, m., ill nine months with severe sciatica;
cured by cinchonine and iron with ungt. veratriae. As the sciatica yielded
he had attacks of frontal pain, and gastrodynia. He was weakly, and his
affected leg was specially weak. Treatment till convalescent=thirty-live
days, total = three months.

SCIATICA. 205

(2.) Mrs. Ab., set. 30, f. Ill two days with severe sciatica, not extending
below ham, attended with great tenderness. Cured by pot. iod. + alkali at
first, + bark afterwards, and aconite lotion in a week.

(3.) F. B., f., oet. 48. Ill three weeks with severe sciatica, unrelieved by
quinine gr. v. te?- die, or by the same + iron, cured by pot. iod. with arsenic
subsequently. Morphia injection failed. Treatment =forty-five days.

(-1.) J. H., m., set. 36. Ill six to seven months with sciatica, health
otherwise good. Very much benefited, if not cured by arsenic internally,
and tinct. aconite with belladonna to the limb. Treatment=thirteen days.

(5.) Mrs. H., f., £et. 30. Has had several previous attacks of left sciatica
much relieved by hypodermic opiate injection. The present came on with
marked signs of failing nerve power, syncopic attacks, delirium especially
nocturnal, restlessness and exhaustion. Recovered well with ammon. carb.,
tr. valerian., tr. arniese, liq. opii sed., inf. valerian. 4:tis Jioris, and arsenic
with change to country.

(6.) W. "W., m., £et. 43. Ill five weeks with left sciatica, most pain over
exit-point of nerve from pelvis, with numbness and crampy pain extending
down limb. But little benefit from iron + quinine, and veratria ointment,
but was cured by two morphia dressed blisters to hip, and pot. iod. + tr.
cinchon. + inf. cascarill. Debility was marked. Whole treatment = two
months.

(7.) J. L., m., agt. 44. Ill three weeks with right sciatica; no benefit
from arsenic and veratria, or arsenic + pot. iod. Cured by cinchonine, and
cinchon. + iron, alterative aperients and emetics.

(8.) W. F., m., get. 65. Ill one year with severe sciatica not extending
beyond knee ; great pain over exit of sciatic nerve. Much benefited by
blister to hip, and veratria ointment subsequently with arsenic internally.
Treatment = seventeen days.

(9.) T. H., m., set. 38, right sciatica relieved by ol. tereb. ttlx ter die,
and linim. tereb. c. opio.

(10.) E. D., m., aet. 46. Ill fourteen days with left sciatica, nervous
debility very marked. Hypodermic morphia injection gave no relief, nor
did pot. iod., nor colchicum, nor ferri carb., nor croton oil aperient at night,
but under the steady use of arsenic gr. gV ^^'* ^'^^ ^^ recovered. The least
exertion caused extreme perspiration.

(11.) L. C, f., set. 52. Ill fourteen days with left sciatica, marked
debility, and vaso-motor nerve disorder. Has flushes of heat succeeded by
perspiration three or four times a day; "fingers die now and then, turn
numb and cold as marble, and the nails become black." Under F. + Q.
citr. and aconite lotion she benefited very much. The motor power of
the limb was impaired somewhat. The neuralgia afiected also the right
side of the face. Treatment= thirty-nine days.

(12.) T. D., m., aet. 45. Ill four months with right sciatica, making
him walk lame. Is getting worse, very weak and emaciating. Most pain
over exit of sciatic nerve. Much aff"ected by change of weather from fine
to wet. Cured in fourteen days by arsenic, and linim. terebinth, c. opio.
He had had ague, been in India, lived at Woolwich.

(13.) J. N., m., set. 42. Ill three weeks with left sciatica, very much
benefited by quinine + iron, and ol. morrh., and one hypodermic opiate
injection.

(14.) H. A., m., set. 49. Ill two months with sciatica of the right thigh,
great debility and starvation. Unrelieved by pot. iod. and tr. colch., or

206 SCIATICA.

arsenic and tr. cinch., or opiate hypodermic injections, but very much by
hospital care and good diet, aided by valerian, ammonia, chloric ether, and
ferri carb. internally, with a morphia blister.

(15.) E. W., f., set. 49. Ill two or three months with left sciatica, affected
limb colder than the other. Not benefited by pot. iod. + bark, with mor-
phia blister, but materially by quinine + iron. The neuralgia showed a
tendency to affect the head.

(16.) C. P., set. 38, f. Ill six months with left sciatica. A morphia
blister, pot. iod. + vin. colch., iron + quinine, and ferri carb. were of no
avail. Quinine gr. 20 in the day was of material use, but arsenious acid
appeared to be the most effectual remedy. Liq. opii sedat. was injected
several tiines with temporary relief. Treatment=six months.

(17.) M. M., m., set. 63. On ad. had had sciatica four to five months
since a wetting while perspiring; health generally perfect ; pain increased
by changes of weather. Left leg/ee/.s- very cold, but the actual temperature
of both is about the same, 90° F. Pain extended quite down to ankle, was
replaced to some extent by numbness in the course of the treatment. He
remained in the hospital seven weeks, had quinine, arsenic, iron, pot. iod.,
croton oil, subcutaneous opiate injections, and morphia blisters, but did not
make very satisfactory progress.

The above cases show pretty clearly that sciatica is for the most
part essentially a neuralgic affection quite similar to neuralgia in
any other situation. The proportion of males to females in my
cases is considerable, 11 : 6, a circumstance which, if not accidental,
may be explained by the greater exposure of the male sex to chills,
&c. The impairment of motor power which often occurs has been
well noticed by Romberg, and is certainly almost as noteworthy a
feature as the pain. It shows that the morbid action is not con-
fined to the sensory nerves, but affects the motor in juxtaposition
with them. Of the nature of this morbid action we can say little
more than that it appears to be identical with that which produces
neuralgia in other situations, that except perhaps in recent rheumatic
cases it is not inflammatory, and especially that it has usually a
positive relation to debility, and will not yield permanently until at
least some degree of strength and vigour is restored. Dr. Rad-
cliffe's suggestion that owing to impaired nutrition some breach
occurs in the oleaginous investment (white substance of Schwann)
of the axis cylinder is I think probable, and at any rate may serve
provisionally as a representation to our minds of the state of the
parts concerned.

Romberg admits the occurrence of a spontaneous cure in connec-
tion with critical symptoms, as diarrhoea, menstrual, lochial, or hae-
morrhoidal discharges. I do not wish to question the possibility of
this ; but according to my own experience the continuance of any
discharges of this kind is much more likely to perpetuate than to
cure a sciatica. Neuralgic disorder is occasionally met with which
affects more the superficial nerves of the lower limb than the deep-
seated sciatic trunk. It is essentially similar to the more common
affection. The diagnosis of sciatica does not generally present any

SCIATICA. 207

material difficulty. Pain extending down the posterior aspect of the
limb in the course of the nerve, especially felt, and increased by
pressure between the ischiatic tuberosity and the great trochanter,
but not aggravated materially by the movements of the joint, or by
pressure of the articular surfaces together, can scarcely be due to
other cause than sciatica. The most important point in refractory
cases especially occurring in the female sex is to determine whether
or not the pain is dependent on any intra-pelvic, or other organic
disease. Churchill mentions a case {Diseases of Women, p. 253)
where an ulcerated uterine cancer produced no pain except in the
whole course of the sciatic nerve. In such cases there will however
almost always be other symptoms, such as discharge, or hemorrhage,
which will indicate the true nature of the disease. It is most pro-
bable that the pain from cancer uteri is of reflex character, and not
occasioned by direct irritation of the nerve. This I conclude partly
because the uterus is too remote from the sciatic nerve, and partly
because fibrous and ovarian growths which are more likely to press
on the nerve do not have the same effect. Trousseau^ declares that
sciatica is often dependent on disease of the vertebral column, kid-
neys, testes, uterus, and rectum, and states that Chomel went so far
as to disbelieve in the existence of essential sciatica. He mentions
a case where it occurred in a young female after delivery in conse-
quence of a slow inflammation of the sacro-iliac symphysis ending in
abscess. The condition here was probably one of neuritis. Though
I have the highest respect for Trousseau's opinion I must say that
my experience does not confirm his and Chomel's view as to the fre-
quency of the remote origin of sciatica.

The disease in some cases has a rheumatic character, the urine
being lateritious and acid, a certain amount of pyrexia being present,
and the strength not much impaired. Here potass, iod. and vin.
colch. with alkali are curative, but the iodide should be given in
pretty large doses, gr. vij — x, ter die. In the majority of instances,
however, there is more or less marked debility, the urine is free and
pale, the tongue clean, and tonics are evidently indicated. Among
these I am inclined to rate arsenic rather highly, as it has served
me well in cases which would scarcely I think have recovered with-
out. I am rather partial to the simple solution in distilled water,
which easily dissolves gr. j'^ per Ij. As a means of improving the
general nutrition, as well as that of the afi'ected nerve, it will be
well to administer ol. morrh. in all cases bearing the stamp of de-
bility. I am aware that some physicians have found repeated small
doses of croton oil of great efficacy, but it has not occurred to me
to meet with such. The remedy should however be borne in mind
in dealing with refractory disease of this kind. I say of this kind,
for it is by no means useful only in sciatica, but also in other neu-
ralgias. This goes far to disprove the view of the mechanical cau-

1 "Clinique Europeenae," No. iii., 1859.

208 SCIATICA.

sation of sciatica, viz., that it is produced by the pressure of scy-
balous masses in the lower bowel. This mayi occasionally be the
case, but certainly it is not common, and on the other hand con-
stipation very often produces no sciatica. I remember an old
man in whom by reason of a large epithelial cancer of the lower
rectum the feces concreted above into masses about as large, and
almost as hard as a walnut, which enemata would bring away; yet
he had no sciatica. I am rather inclined to look upon croton oil as
acting in certain cases as a specific stimulant to the nervous system.
Cases no doubt occur where local bloodletting is necessary, but I
can scarcely believe that venesection can be requisite as Romberg
states. If this is ever the case, it must be when there exists con-
siderable pyrexial disturbance of a sthenic character, and this might
be always allayed I should think by other means. 01. terebinth,
has maintained for some considerable time its reputation as a remedy
for sciatica. I have used it but little, chiefly because the state
of the general system has seemed to require more decided tonics.
I consider it most appropriate to those conditions where there is
no marked debility, or indication of recent rheumatism, or of or-
ganic disease. Hypodermic opiate injection gives considerable
temporary relief in some cases ; it is apt, however, to cause much
distressing nausea and sickness. It is scarcely desirable to use it
except where the suffering is severe. As a local application if the
pain be severe, and the limb intolerant of pressure, I think aconite
lotion is the best. If the pain be more gnawing and wearying and
tenderness be not marked, chloroform and opium liniment is pre-
ferable. Veratria ointment and belladonna are appropriate to cases
where the tenderness is less than in those requiring aconite. Some
physicians have much confidence in " firing," I do not mean using
the actual cautery, but iron heated by being dipped in boiling-
water. Dr. Graves indeed states that in very obstinate cases the
actual cautery applied to five or six spots along the course of the
painful nerve is the means most to be relied on. I should consider
this, however, quite a " dernier ressort," and certainly not to be em-
ployed unless I was well satisfied of the absence of organic disease
as well as of general debility. It cannot be too clearly kept in
mind that as long as the latter continues no real improvement can
be effected. Dr. Fuller speaks highly of acupuncturation, and there
is no doubt of its frequent efficacy in this and other neuralgic affec-
tions, although I am not convinced that its virtue depends on the
evacuation of effused fluid. Dr. Althaus has found faradization of
the affected nerve effectual in sciatica, I can quite believe that
this is the case, but it is requisite in using the interrupted current
to take care, (1) that the condition is not one of inflammation, and
(2) that the strength of the current is not too considerable. I am
satisfied that the pain may be aggravated if this caution is disre-
garded. Torri^ relates ten cases of sciatica cured by weak con-

' "Gazz. Med. Ital. Toscan." 1857, Nos. xlii., xliii.

SCIATICA. 209

tinuous currents kept up uninterruptedly for two days. The posi-
tive pole was applied to the leg, the negative to the thigh, the epi-
dermis having been previously removed at each spot, and a sponge
moistened with saline solution placed in contact with the cutis. The
pain of this proceeding we can aver must have been severe, and we
are not surprised to read that the skin in contact with the zinc
always became gangrenous and required some time to heal. The
pain may have been lessened by the half grain of morphia which
was placed upon the denuded cutis. A case is recorded by Hooker'
in which division of the popliteal nerve was successfully resorted to
for severe neuralgia of the leg. Jobert de Lamballe^ has also di-
vided the sciatic (and crural) nerves in a case of great severity, but
though much relief was afforded the patient died from sloughing
of the skin over the sacrum and pyaemia. He renounces this ope-
ration in favour of the actual cautery. Finco^ reports that he has
treated 48 cases of sciatica by cauterizing the ear. In 30 the ope-
ration was quite successful, in 10 partially so, in 8 it failed. The
failure is ascribed by F. to the presence of various complications.
In almost all his cases vigorous antiphlogistic treatment was em-
ployed before the cauterization, and in some its effect was aided by
mercurial or belladonna ointment. The operation had to be repeated
only in 3 cases. Duchenne* rejects the use of the cautery, but
thinks that the interrupted current may be employed in its stead.
He prefers, however, to act loco dolenti, using dry conductors.

Crural Neuralgia.

My experience accords with Romberg's that this is a much rarer
affection than sciatica, but that in essential points it closely resem-
bles it. Direct irritation of the nerve from a loaded intestine or
some similar cause may give rise to it, but less frequently I think
than the obscure influences which so commonly produce nerve dis-
order. The possibility of neuralgia and impaired motor power of
the thigh being dependent on the existence of obturator hernia
should be borne in mind, and if any symptoms of intestinal obstruc-
tion are observed, an operation should be at once performed. The
following case is an example of non- organic crurai neuralgia.

Case 18. — Mrs. F., set 65, seen June 14th. A frequent sufferer from
neuralgia affecting various parts. Was attacked yesterday in afternoon
with intense pain affecting both lower limbs from the hips to the ankles and
heels. The pain was diffused over the front and exterior of the limbs, and
was attended with a sense of powerlessness. She kept rubbing the parts
constantly in hope of relief. Functions in order. The pain continued
severely from 5 P. M. to 1 A. M., remitted then somewhat, but returned

« "Lancet," Oct. 1, 1859. 2 " L'Union M^d.," No. Ixxvii., 1859.

* " Gaz. Lombard." xxsviii , xxxix., xU., 1860.

* " Tr. de Therapeut." par Trousseau et Pidoux, vol. i. p. 787, 788.

14

210 ANGINA PECTOKTS.

again at 6 A. M. severely for a short time. Up to noon of 14th she had
no sleep in spite of itl 120 of liq. morph. bimecon. given since the previous
evening. A liniment of chloroform, belladonna, and opium gave no relief.
Quinine given to moderate cinchonism subdued the pain ; on 15th she was
quite free. Some slight nocturnal fever occurred as the neuralgia yielded.
For some weeks before her attack her nervous system had been much
deranged in consequence as she thought of a thunderstorm.

In another case a delicate boy, set. 9, had agonizing pain in his
feet occurring in paroxysms succeeded by copious perspirations.
Pot. iod. 4- pot. bicarb, was of no benefit, but with citrate of iron
and quinine he soon got well.

CHAPTER XXVII.

ANGINA PECTORIS.

My noticing this disorder among the functional diseases of the
nervous system will show that I consider it to be au fond a neu-
ralgia. Dr. Watson objects to this view :* (1) because the paroxysm
is excited by such causes as are especially calculated to disturb the
natural action of the heart, bodily exertion, and mental emotion ;
and (2) because the disease is so very frequently and suddenly fatal,
which is not the character of mere neuralgic diseases in general. To
this it may be replied that exertion and mental emotion are causes
which do very much increase and even induce various neuralgise.
A gentleman about whom I was lately consulted suifered with an
obstinate neuralgia of the side of the chest, which subsided on his
remaining perfectly still, but was immediately reproduced by moving
about. Neuralgia in other parts is not fatal just because the func-
tion of the organ is not essential to life. No one can be surprised
that " tic douloureux," or sciatica, or the like should not endanger
life. Dr. Stokes,^ from his examination of the subject, concludes
that the special group of symptoms described as angina pectoris is
but the occurrence in a defined manner of some of the symptoms
connected with a weakened heart. Obstruction of the coronary
arteries he considers as no necessary condition. According to this
view a weakened state of the heart is essential. I cannot agree
with this, as I have certainly had patients under my care with con-
siderably weakened hearts who presented none of the symptoms of
angina pectoris. And again I can adduce one if not two cases
where after death from this affection the heart was found in a toler-

• "Lectures," vol. ii. p. 259.

^ "Dis. of Heart and Aorta," p. 487.

ANGINA PECTORIS. 211

ably healthy state. Something there must be I think beyond simple
weakening of the organ to account for the peculiar phenomena of
the disease. It is however quite reasonable to believe that a variety
of morbid changes may predispose to it, and indeed this seems to
be the fair inference from the observations which have been collected
by Dr. Forbes. This opinion seems to be that entertained by Dr.
Copland. Dr. Latham regards the disease as spasm of the heart,
insisting on its analogy to cramp in the voluntary and involuntary
muscles, and on the efficacy of opium in relieving the distress.
Lussana adopts the same view, citing an observation of Morgagni's
who found at an autopsy the heart " durum valde et robustum," and
another one of Carron d'Annecy where the heart was very much
contracted. He thinks it demonstrated that the heart's muscular
tissue during the attack is in a state of cramp like contraction, and
remarks that the character of the pulse as generally observed is in
conformity with this view, being brief, small, hard, and often accele-
rated. V. Schmidt's Jahrb., vol. 108, p. 312. Dr. Walshe' says
that " angina pectoris seems to be constituted by spasm of the heart,
and neuralgic pain," and doubts whether it ever occurs without some
kind of structural change in the organ. It may be remarked that
a cramp-like condition of the heart's tissue would quite as much
interfere with its functional action as a paralytic state. It is quite
as essential for the heart to relax duly to admit blood into its cavities,
as it is that it should contract and expel it. The pallid face, sunken
features, and feeling of impending dissolution may quite be ac-
counted for on the view held by Latham. Lussana states, what
seems scarcely in accordance with general experience, that after the
attack the continued contraction of the muscular fibres is succeeded
hj languor, exhaustion of irritability, and finally paralysis, to which
even the pain itself contributes. Therefore the heart of anginose
patients falls after the attacks into a condition of collapse, and the
circulation is languid and feeble, so much so in some cases that the
pulse and the heart's impulse become imperceptible, and the patient
at last becomes faint and dies quietly. Dr. Stokes, on the contrary,
speaks of the pulse during the attack as being almost imperceptible,
and says nothing of any subsequent syncopal state. Morgagni and
Carron found in two patients who died during the attack the right
cavities completely empty, and the left ventricle nearly so, the pul-
monary artery and the vena cava on the contrary distended with
blood, which was black and quite fiuid. In patients who had died
in the intervals of the attacks coagulated or fluid blood was found
in larger or smaller quantity in the cavities. Lussana regards the
latter as indicating paralysis, the former tetanus of the Ijeart. He
thiuks generally that the blood of anginose patients is but slightly
coagulable ; in one of my own cases the fluidity of the blood was

i " Dis. of Lungs and Heart," p. 434.

212 ANGINA PECTORIS.

remarkable. His final conclusions are that the disease may be
dynamic or organic ; but that for the most part it is the latter,
being in fact produced by mechanical irritation of the cardiac plexus
resulting from calcareous degeneration of the coronary arteries of
the heart, or some similar cause. It is thus invariably a neuralgia,
whose sole and constant seat is the cardiac plexus.

The three following fatal cases in which autopsies were made
came under my own observation.

No. 98. — J. 0., set. 39, m. Seen Dec. 15fch. Always had a rosy colour.
Never bad rheumatic fever, but had pain in left temple, stopped by local
applications. Has been ailing several months. About nine weeks ago had
the first attack of pain in his cheat, " it turned his face white/' Up to
Nov. 16th, when he was admitted as in-patient, he had the attack once in
two or three days. While in hospital he had a short hacking cough, pain
in epigastrium extending up to the throat increased by walking, which also
brought on palpitation. Heart's action regular, loud diastolic bruit at base
and apex, cardiac dulness not increased, impulse at times heaving and strong.
Weak breathing all through both lungs. Urine healthy. Temper irritable.
Left hospital Dec. 8th in same state. When he came under my care he
complained of a constrictive sensation at the epigastrium, "like a rope
round him.'' The same sensation was brought on by walking to some
extent. At times he had a dreadful amount of flatulence. Appetite very
good, but is afraid to eat. Looks well. Pulse 54, weak, intermitting every
now and then. Heart's action trembling, the contractions appear to be not
steadily sustained. Ordered argenti nitrafc. gr. | + extr. byoscy. gr. ij ter
die, with ammonia, spt. seth. s. co., and tr. hyosey. On 21st and 22d he
suffered much from pain in front of his chest during the night up to 4
A. M. On 24th he had pains in his chest as usual till 7 A. M. when he
screamed out violently, turned over, and died immediately. I was informed
that he had latterly had an attack twice or thrice daily, each attack lasting
one hour, during this time the epigastrium was hard and swollen. In the
intervals he was quite free from pain. Taking even very light food, or
riding, or walking brought on the paroxysms. In one of the latter, if not
the last, the pain extended to the left arm, affecting it severely. He used to
open his dress and rub his chest when suffering. His wife thought he had
a tendency to insanity. Post-mortem. — Lungs quite healthy. Some fluid in
pericardium. Heart about normal size, very decidedly flabby, muscular
tissue appeared healthy, large loose clots in auricles. Aortic valves did not
hold water ; they were thickened, but quite flexible. Just above one of
them, in the sinus of Valsalva, there was a large patch of calcareous deposit,
about J by i inch ; it lay close to the orifice of a coronary artery. The
coats around were healthy. Mitral valve a little thickened, but quite
efiicieat. Right valves healthy. Muscular tissue of the heart was markedly
affected with fatty degeneration, the fibres full of minute oil molecules, and
their nuclei broken up into masses or streaks of oily molecules. Liver and
stomach quite healthy. Body in good condition, muscles of a good dark
colour, and in a decided state of rigor mortis, which was not the case with
the heart.

No. 99. — Mr. H., set. 57, a stout, large-made man, had been to the races
on 27th, and rather deranged his digestion as he thought with melons and
champagne. He complained on SOth of a very distressing pain across the

ANGINA PECTORIS. 213

upper part of his cbest ''as if an iron network was there instead of flesh,"
but there was no disorder of the sounds or rhythm of the heart. He was
very fidgety and nervous, and anxious for relief, and of his own accord applied
hot water to his chest, so as to raise a small blister. The pain in his chest
came on while he was walking up a hill on 27th and continued till his death.
He had always a presentiment of sudden death, often spoke of it; his father
died of disease of the heart. On 30th he had a dose of calomel + opium,
some brandy, and olei ricini, and one dose of soda + acid, hydrocy. dil.
Tt\^iij. Shortly after this he died suddenly, just after leaving the night-
stool. Post-mortem — Lungs much congested, but crepitant throughout and
healthy. Heart of normal size, cavities open, containing as well as the
large vessels much fluid blood, and scarce a trace of clot. The heart's
tissue was rather flabby, of good colour, the muscular fibres of both ven-
tricles showed only fatty degeneration of their nuclei, the bulk of each fibre
was quite healthy. The subpericardial fat encroached to some extent on
the muscular tissue in some parts, but the walls of the cavities were not
thinned. The left coronary artery was extensively affected by atheromato
calcareous deposit, which narrowed at some parts of its canal decidedly.
The right coronary appeared healthy, the mitral and aortic valves were
healthy, the others were not specially examined. No coagula in the large
pulmonary vessels. Tracheal and bronchial mucous membrane was very
highly congested and dark. The abdominal viscera all appeared healthy.
The stomach contained a little fluid ; its mucous surface was pale and
normal.

No. 100. — X. Y., a robust man, aet. 54, was under treatment a short
time with inflammation of the left testis of moderate severity. It was
getting better, and he was not otherwise ill at all He had been under
treatment on previous occasions, but had never had any serious illness.
About the middle of the day he was suddenly attacked with severe pain in
the region of the heart. His medical attendant had seen him the same
morning, and found him apparently well. In fifteen or twenty minutes the
man was dead. Six leeches had been applied on three separate occasions to
the testis ; the patient had sufi'ered some mental anxiety, but was in tolerably
good circumstances. At the post mortem the rigor mortis was well marked,
the body muscular, and in good condition. Heart flabby, its walls were
perhaps rather thinner than normal, and its tissue of a less decided red.
On microscopic examination some degree of fatty degeneration of the fibres
was found, but not by any means enough to account for the fatal event.
There was slight atheroma of the coronary arteries. Brain not examined.
Thoracic and abdominal viscera healthy.

Remarks. — The morbid changes in these three cases were mate-
rially different, and yet the disease was in all I believe the same.
In the first it is probable that the patch of calcareous deposit pressed
on and irritated some nerve, which then exerted on the cardiac
ganglia a depressing inhibitory influence. The degenerated mus-
cular tissue would be all the more readily paralyzed from its
enfeebled state. In the second case there seems no adequate
explanation to be given of the sudden supervention of the symptoms,
as it must be supposed that the disease of the coronary artery had
existed for a long time, and the heart so to speak must have become

214 ANGINA PECTORIS.

habituated to it. In the third case there appeared absolutely no
cause for the fatal event. The occurrence of such cases as the last,
the absence of any constant morbid condition in instances where
organic disease is found, and the frequent existence of all kinds of
organic lesions without any trace of angina incline me very much
to believe that the essential circumstance in the disorder under con-
sideration is an attack of neuralgia, quite similar to that which
would be unimportant elsewhere. This seems to be nearly the
opinion entertained by Trousseau, and is further supported by the
complete cures of the disease which have occasionally been accom-
plished.

Bernard tells us,' and the observation is highly important, that
irritation of a posterior spinal root causes temporary arrest of the
heart's action continuing for fifteen or twenty seconds; he even
intimates that in a weakened animal fatal syncope might be produced
in this way. It is however noteworthy that cerebro-spinal neuralgia
however violent does not (in the human subject) seem to have much
tendency to induce syncope, whereas this is apt to ensue on irrita-
tion of the sympathetic plexuses. If we conceive such a pain as a
severe gastralgia befalling the cardiac plexus we may well imagine
that it would occasion arrest of the heart's action. I am much
inclined to coincide with Laennec's statement, quoted by Romberg,^
to the effect that " in a slight or moderate degree angina pectoris is
an extremely common affection, and exists very often in individuals
who are free from any organic affection of the heart or of the large
vessels. I have seen many persons who have experienced only some
smaut attacks, but of short duration, and who have afterwards been
freed from them, I even believe that the influence of the medical
constitution contributes to its development, for I have observed it
frequently in the course of certain years, and I have hardly met
with it in others." Romberg's statement that arthritis and hysteria
are the chief predisposing causes of this disease appears to me by
no means well founded, certainly at least as regards the latter.
Neither can I remember to have met with angina in any of my
gouty patients; I can scarcely think that the podagrous are notably
more liable to the disorder than others. Rheumatism appears to me
to have much more relation to angina pectoris than gout has, and this
may be the reason that certain states of cardiac disorder of anginose
character are remarkably relieved by pot. iod. I am speaking here
of the apyretic form of rheumatism, such for example as produces
a stiff neck. Believing as I do that angina pectoris is essentially a
neuralgia, there is nothing surprising to me in the occurrence of
minor degrees of it, or to speak more exactly, of various forms of
dyssesthesia or neurosis of the heart. True, these are not likely
often to pass into the graver disease, but they indicate nevertheless

• "Legons," vol. i. p 269.

2 "Dis. of Nervous System," toI. i. p. 126.

ANGINA PECTORIS. 215

the tendency of tlie nervous structures of the heart to be morbidly
affected. This is a material point, as any tendency to implication
of vital organs is always to be regarded with suspicion. Thus of
two persons who on exposure to malaria should contract, the one a
severe tic of the face, the other a moderate cardiac neurosis, I should
have no question in estimating the former as the more lightly visited.
It is perhaps impossible to offer any satisfactory arrangement of
cardiac neuroses, the most useful way will be I think to cite some
interesting examples I have met with, and to make some comments
upon them.

Before doing this I would remark shortly on the great influence
of gastric disorder on the heart. This is a matter of the com-
monest experience, but it seems to me to be by no means sufficiently
explained. In the first place I think it must be allowed that mere
flatulent distension of the stomach disturbs materially the action
of the heart, the relief procured on dispersing the flatus being im-
mediate. I should be much inclined to ascribe this disorder of the
heart solely to inhibitory action of the gastric nerves, were it not
that it is certainly aggravated by lying on the left side, which by
bringing the weight of the liver and other viscera to press on the
stomach pushes it upwards against the diaphragm and the heart.
The cardiac uneasiness from this cause sometimes takes the form of
a sharp precordial pang, which forces the person to turn immedi-
ately from the left side position from the sensation that if he did
not the heart's action would be arrested. The distress in this case
seems to be of mechanical origin. There is certainly I think some
peculiar relation between flatulency and cardiac disorder. A gentle-
man whose heart is apparently free from organic disease, and who
has no gouty tendency, but some rheumato-neuralgic, finds that
when he has been debilitated by various causes, over-exertion in
walking produces a tendency to syncope and flatulence. It appears
as if both resulted from the same cause. He has no dyspepsia, but
has found that sudden mental excitement or emotion will suddenly
bring on flatulency when he was previously quite free from it. The
extraordinary rapid development of flatus (rectal), which occurs not
uncommonly in malarious dysentery, ceasing as suddenly as it com-
menced, and taking the place of diarrhoeal discharge is almost
sufficient to prove that flatulent disorder may be dependent upon
nerve affection. No one can I think have had to deal with these
cases without being impressed both with the neurotic character of
the disorder and the utter insufficiency of any mere decomposition
of intestinal contents theory to account for the phenomena. From
my own observation of both gastric and rectal flatulence I am much
disposed to lay down as a proposition, that mucous membranes under
the influence of enfeebled innervation may secrete large quantities
of gas. Trousseau' affirms that flatulent distension often occurs

1 " Cliniq. Med.," vol. ii. p. 354.

216 ANGINA PECTORIS.

quite independent of fermentation. Cardiac distress and debility
may be co-results of the same nerve disorder. The best remedies
for cardiac uneasiness depending on flatulence are creasote in pills
with quinine and a little ginger, or creasote in solution with muriatic
acid and tr. calumbse. The following case is a well-marked example
of the association of cardiac and gastric disorder.

No. 101. — M. L., f., set. .53, ad. January 23d, ill three months. Com-
plains of dreadful palpitation of the heart mostly felt at night, preventing
her from lying down or getting sleep for hours; sometimes she can hardly
breathe. The palpitation causes a hammering noise in head. Has much
flatulence and spasm at the stomach (severe pain darting from between the
scapulae to the sternum, and up into the neck). If she can disperse flatus
is easier. Food does not digest, turns to wind. The heart does not appear
enlarged, there is a loud rough systolic bruit at the base extending some
way along the the aorta, second sound distinct lower down, rhythm normal.
She says the heart seems to stand still at times. Is very weak, always
thirsty. Epigastrium very tender. Takes no tea. Has prolapsus ani.
Nitrate of silver with henbane was given with good eff'ect in calming the
excited action of the heart, but muriatic acid with prussic and inf calumbae
was rather prejudicial, a combination of strychnia, ferri sulph. and tr.
zingib. proved however most useful. As long as she took it she had- toler-
able appetite, and was able to digest and to lie down and sleep at night.
The heart's action became much quieter, and the pulse notably weaker than
it had been at first. Stout she found beneficial, but had to omit it occa-
sionally. Mutton, cocoa, and bread she was able to digest very tolerably.

In this case it is quite certain that the gastric disorder as well as
the cardiac was a neurosis. Had it been otherwise the strychnia and
iron would surely have proved the reverse of beneficial. Flatulent
distension of the stomach no doubt aggravated the cardiac disorder,
but did not originate it. Both were I believe co-results of the same
neurotic condition, and both were benefited by the same treatment.
The calming of the excited heart's action under nervine tonics is a
curious and interesting phenomenon, and almost necessarily suggests
to us the opposite results of dividing and galvanizing the pneumo-
gastric nerves. In one very marked instance which occurred to me
many years ago the patient had had diarrhoea, vomiting, loss of
appetite, and sleepless nights for two or three days ; she was very
weak, inclined to faint, and felt as if she would sink through the
bed on which she lay ; yet the pulse was regular, large, rather
forcible, 100. Under quinine 9 grains a day, she gained much
strength, and the pulse became weaker, from the heart acting more
quietly. The effect of large doses of quinine in slowing the pulse
is very similar to that of galvanizing the pneumogastrics, and the
result is probably attained through the same channel. It is in in-
stances of the kind above related, well known to practical men, that
we have good examples of the truth of the distinction made by
Barthez' between radical and acting forces. The former may be

1 "Traite de Tlierapeut," par Trousseau etPidoux, vol. i. p. 43.

CARDIAC NEUROSES. . 217

nearly exhausted while the latter are in full play; and vice versd
the latter may be but slightly manifested while the former are
powerful. The amount of the radical forces represents a person's
capacity of vital resistance to disease and to fatigue. Two persons
may have the same apparent strength and capacity for action, but
one, to use an expressive term, has much 'more "last" in him than
the other, withstands fatigue much longer, and resists hardship and
morbific causes much better. The acting forces according to Bar-
thez have their origin in the radical, and these are especially in-
creased and sustained by quinine and other tonics, though of course
they are dependent essentially on the due maintenance of the various
vital processes by food, pure air, repose, &c. It is very noteworthy
that there is often a distinct consciousness in the system that these
radical forces are failing. The pulse and respiration may be good,
there may be no evident signs of impending collapse, and yet the
patient may feel that he is gravely stricken, and have a presentiment
of dissolution which is not unfrequently verified. I well remember
myself during the cholera epidemic of 1854, a full hour before I
was attacked with a form of the disease, laying down the pen as I
was writing at night surprised at the sudden strong presentiment
of death which came over me. My mind was quite calm and clear,
my bodily functions were unaffected, and I looked upon the feeling
for some time as a curious psychical phenomenon. This however
by way of digression. The depressing influence of certain matters
taken into the stomach upon the heart is well known, as for instance
that of large draughts of cold water, or of lumps of undigested
food. Mr. Higginbottom has recorded' some well-marked examples
of "syncope senilis" resulting from the latter cause, and relieved
speedily by the administration of an ipecacuan emetic. Such cases
seem to me best explained on the view of inhibitory action, the
morbid stimulus being reflected from the nervous centres on the
cardiac nerves. Tea is so notorious a disturber of the heart's tran-
quillity that it needs little more than a bare mention. I am satisfied
that it is not solely an idiosyncrasy which renders it a very poison
to some individuals, but that acquired nervous debility may have the
same effect. The gentleman whose case I have alluded to above
used to take tea freely and enjoy it until the last five or six years
without experiencing any ill effects. Now it renders him sleepless,
hyper^sthetic, weak, and produces a sensation of precordial uneasi-
ness and of failing action of the heart. Coffee if continued a few
days has the same effect, but cocoa has not. The remedy in such
instances is not only omission of the injurious article of diet, but the
employment of all means capable of increasing nervous energy. It
may be mentioned as illustrative of the change wrought in the
nervous system by the toils and cares of life, that the same man to
whom tea is now a poison drank it instinctively as the most reviving

> "Lancet," April 20, 1856.

218 CARDIAC NEUROSES.

beverage twenty-four years ago towards the close of an eighty miles'
rowing match. Many Alpine tourists find cold tea an excellent
refresher in their mountain clamberings. It is plain enough that
to a tolerably firm nervous system tea is a grateful and useful
stimulant. Its poisonous and depressing action on the weak and
shaky system may be explained I conceive on the principle before
referred to, viz., the production of hyperaesthesia by debility. When
the nervous power has become enfeebled the plexuses of the coronary
arteries partake of the morbid sensibility, and are excited by tea to
produce contraction of the vessels. The heart is thus imperfectly
supplied with blood, and its action is consequently feeble and
flagging. In other instances where palpitation is produced it is
probable that the stimulus tells more upon the muscular tissue of
the heart than upon the coats of its vessels. M. Beau^ has lately
remarked on the production of angina pectoris by the use of tobacco,
and records eight cases in evidence, two of which proved fatal.
Judging from the action of nicotine in tetanus, and from the effect
of tobacco enemata it would seem probable that tobacco exerts a
directly paralyzing influence on the heart. Rouget^ however shows
by experiment that its action is the reverse, that when applied
directly to the heart it causes a permanent tonic contraction ; and
that if it be applied to the motionless and dilated ventricles of birds
and mammals killed by the inhalation of chloroform, it restores for
a time the contractions, and at last induces tetanus of the tissue.
This statement goes to support the theory of spasm.

The cases I propose to relate may be distinguished as rheumatic,
malarious, saturnine, and connected with " goitre exophthalmique."

No. 102. — C. R., a3t. 35, (?) of sanguine habit, but rather weak nerve
power, had been exposed to cold more than once, and suffered from stiff neck
and a most unaccountable malaise. His digestion was usually good. Four
days later, having had a fresh chill in the interval, he took a hurried meal,
and on returning had a nap as usual. He awoke with a very curious sen-
sation of spasmodic choking all along the oesophagus. He went to bed and
felt somewhat relieved by the warmth, so that he slept for about one hour.
He then awoke in the most excruciating pain, could only lie in one position,
viz., on the back slightly inclined to the right side with the left leg drawn
up. He could not breathe without great pain. " I dared not," he says,
" close my eyes from experiencing that most awful sensation as if my heart
would cease pulsating, the agony I went through that night baffles all de-
scription." For two hours he was involuntarily kicking; though well aware
that he was doing so he seemed to have no control over his limbs; and if he
chanced to kick himself the feeling was a most curious one, " as if one leg
did not belong to the same body." A mustard and turpentine poultice to
the chest afforded some relief. When I saw him early the next morning
the pulse was excited, the tongue pretty clean, urine scanty and high-co-
loured, sounds of heart and lungs healthy. He took calomel and opium of
each gr. ij immediately, and had his chest rubbed with a liniment of aco-

' ".J. de M^cl. et de Chirurg. Pratiq.," July, 1862.
2 " J. de la Physiol.," 1860, p. 569.

CARDIAC NEUROSES. 219

nite and opium. After sleeping two or three hours he awoke and began to
take muriate of ammonia and bicarbonate of potash quater die. The next
day the urine deposited a h»teritious sediment; he was much better, and in
forty-eight hours from the time I saw him he was convalescent, and had no
relapse. Both before and after this attack he has sufferred from rheuma-
tism^ muscular and periosteal.

In this instance it is quite certain that the disorder was a rheu-
matic neurosis, and that there was nothing whatever imaginary in
it. The nervous and muscular apparatuses of the heart and oeso-
phagus were especially involved, as well as the intercostal nerves.
According to Bezold' the nervous centre of the cardiac movements
furnishing three-fourths of the entire propulsive force of the heart
occupies the cervical region of the cord including the medulla ob-
longata, and extends as low as the fourth dorsal vertebrsf. Its
fibres run through the cervical spinal cord, and pass out between
the seventh cervical, and fifth dorsal vertebra, probably passing
through the lower cervical and upper dorsal sympathetic ganglia,
and proceeding to the heart. If we suppose that in ordinary cir-
cumstances the rheumatic disorder in the above case would have
assumed the 'form of intercostal neuralgia it is not difficult to under-
stand how by extending backwards and involving the origins of the
upper dorsal nerves it induced the very peculiar cardiac distress.
The involuntary kicking seems to have depended on an excited state
of the lower dorsal and lumbar cord, the action being of a somewhat
reflex character. The altered sensation was probably also due to
central disorder. The case seems to me of interest from the evi-
dence it aff"ords that neurotic as well as febrile rheumatism has a
tendency to affect the heart.

No. 103.— M. A. W., f., set. 44, ad. March 12th. Resides near Uxbridge;
no ague in vicinity. Had rheumatic fever two years ago, since which time
her heart has never been quite right. Ill now one month. States that at 10

A. M. and 7 P. M. daily she experiences a sense of fulness in praecordia, and
of faintness, with pricking and shooting in the same situation, and " deathly
feelings." She can't lie down well at night. The heart's action is now
quite normal and regular, and the P. also. She is a stout person, rather
full coloured. Appetite is bad; she has thirst, but her food digests fairly.

B. open. Urine sometimes thick. Tea twice a day. Tea was forbidden,
and she was ordered creasote and rhubarb in pills his die, with ferri pot.
tart, -j- pot. iod. -f pot. bicarb, -f inf. calumb. ter die. 26th. A great deal
better, pain at heart nothing like it was, nerves much better, urine clear.
She continued in an improved state, but with some relapse from exertion in
nursing, and on April 20th the mixture was changed for pot. bicarb. + spt.
ammon. CO. -f inf. gent. co. On this she kept very well as long as she persevered
in taking it, but if she omitted it and the pills for two days the symptoms
recurred. June 11th. She described the attacks which came on when the
medicines are omitted as follows : " The heart feels so cold as if it lay in cold
water; she could feel a stifling sensation which obliges her to get up and go
into the open air ; her sight gets dim, her head feels lost, and all her senses

i "Wien. Med. Wocheuschr.," Dec. 20tli, 1862. "Brit. Med. J.," Feb. 7th, 1863.

220 CARDIAC NEUROSES.

leave her." The attacks last half an hour and occur at irregular times now. ■
After this she took F. + Q. citr + pot. iod. gr. ij ter die, with which she "
benefited very much, and by July 2d was fairly recovered.

I regard the disorder above described as of rheumatic nature
from the previous attack of rheumatic fever, which probably inflicted
some damage on the nervous apparatus of the heart, from the good
effect of pot. iod. and alkalies, and from the occasional lateritious state
of the urine. I believe, though I cannot put my hand upon the notes
of the case, that she had a son who died soon after of rheumatic
heart disease. In her case the affection was evidently a neurosis,
and though quite controlled for the time I think it is highly probable
that it will return, and may be aggravated by gastric disorder or
the like so as even to end fatally.

The next group are instances of malarious infection.

No. 104. — M. S., set. 41, of active but nervous temperament, latterly
residing in London, but having lived for many years in Australia, was
subject to winter bronchitis. Jan. 9th. Having had on the previous day
marked symptoms of commencing catarrh she was attacked about 8 A M.
with distress referred to the heart, a sensation as if she were dying, breath-
lessness and anxiety. I saw her about 10 A.M., when I found the P. at
the wrist almost utterly gone, the hands cold, the same distress continuing.
The action of the heart on auscultation was very rapid, the sounds normal
and loud, the face pale, and the eyes sunken. Her voluntary muscular
power was not materially impaired; she sat up readily, and stretched her
limbs vigorously. More than once she expressed a dread of going to sleep
lest she should never wake again. She seemed too restless and anxious to
sleep or lie down. Stimulants were given freely, mustard poultices applied
to the precordia, and the interrupted current passed from the nape of the
neck to the same part. Very little improvement was produced for some
time J the P. continued fluttering and most indistinct, but at last warmth
began to return in the hands, and the P. improved. She took gr. iij of
quinine at 11 A.M. and 1.30 P.M. For a good while before and after the
latter hour the cerebral functions were much disordered. There was evi-
dent delirium. About 4 P. M. she became much quieter, but complained of
extreme weakness. The P. was 108, of tolerable force; the T. remained
clear, but appeared to her to be dry, though it was fairly moist. She vom-
ited once about the middle of the day, and coughed up a few times a little
phlegm; butalmostallthe catarrhal symptoms had disappeared; 10P.M. com-
plains of extreme debility and perspiration breaking out. Quinine gr. iij at 5
and 9 P.M. In the course of the next day gr. iij of quinine were taken, and
at the same rate for another half day. She then had a little calomel and
rhubarb, after which she slept well. No medicine was now given till 15th,
when she began citrate of quin. and iron, gr. v ter die, which she took for
nearly fourteen days, and was quite well by 30th. The cardiac symptoms
never recurred severely, but she had more than once uneasy sensations
about the chest, which made her fear a relapse, such as fluttering action of
the heart and great weakness. One of her daughters about the same time
had an attack of bronchitis attended with a decided aguish disorder recurring
every morning, consisting of shivering and depression, and ceasing under the
administration of quinine together with the bronchitis.

CARDIAC NEUROSES. 221

Feb. 3d. M. S. was attacked again about IIP. M. with decided rigors, and
violent beating of the heart in repeated paroxysms, with great depression
and mental disturbance manifested as before by constant loquacity, and a
tendency to repeat the same question over and over again. The P. at 2.30
A. M. when I saw her (4:th) was soft and quick ; the skin fully warm ; the
T. parched and dried up and coated. She complained of breathlessness,
threw the clothes ofF her, her legs felt as if they did not belong to her, and
her hands tingled. I gave her liq opii sed. + spt. geth. chlor. and the symp-
toms gradually subsided. At 7.30 A. M. she began to take quin. dis gr. ij
3 tiis horis. 5th. Was better all yesterday until IIP. M. when the same
symptoms recurred, but less severely. She got some tolerable sleep, but
experienced in the morning some disorder of the heart's action with a
feeling as if she were dying. This subsided after some time, and she re-
mained till the afternoon weak and depressed. She was cinchonized. 7th.
After a tolerable day on 6th, the appetite however being very bad, she
began to have about 9 P. M. " internal tremors," and exceeding restlessness,
which passed into high fever and was succeeded by profuse sweating when
she at last got to sleep. This morning is very weak and prostrate with
utter aversion to food and much nausea. Ice to swallow and mustard poul-
tices to epigastrium. On 8th resumed quin. dis. gr. ij ter die, and on the
10th began ferri and quin. citr., this she took with benefit for four days,
and then went to the country. She returned in about a month much im-
proved, but having still in the evenings slight byt distinct paroxysms of
aguish character. Nov. 7th. Up to about this date she continued well
and active; she woke up about 2.30 A. M. with palpitation and distressing
uneasiness at the heart and pain in the back. I saw her at 4 30 A. M. and
found the heart beating rapidly, its sounds very clear and sharp, the P.
thready and indistinct, and the hands coldish. She was wakeful and afraid
to sleep ; her legs felt as if they did not belong to her. After two doses of
chloric ether + liq. opii sedat. the P. became more distinct, the pain in the
back less, the hands warm, and she went oflF to sleep. With quinine and
iron she was well in about ten days. It is now nearly six years ago since
these attacks occurred, and there have been no signs since of any serious
heart affection.

I have the most perfect assurance that in the above case there
was an entire absence of all hysterical fancy. The patient had
passed much of her life amid the stirring scenes of a colony, and
was one of the last persons in the world to plague herself and others
"with imaginary disorders. She had once been accidentally poisoned
with sulphate of zinc, and had never had the same health since.
She had also once suffered with a head affection from excessive heat,
■which subsided after an eczematous eruption had appeared on the
scalp. The first attack, which was the severest, had a very serious
aspect; her own apprehensions of impending death were very strong.
I was puzzled by it at first, as I could not see why the pulse should
be absent while the heart was acting violently. In the subsequent
attacks when I had a clearer notion of the causation of the phe-
nomena the course to be pursued was apparent. The attack was in
fact essentially the cold stage of an ague, in which, owing to a
peculiar irritability of the vaso- motor nerves, the arteries were

222 CARDIAC NEUROSES.

unusually constricted. The circulation was thus seriously interfered
with, and the heart had to struggle against the obstruction. As
soon as the arterial spasm yielded the difficulty and danger were
over. The cerebral disorder shows how specially the nervous
system was affected by the poison. In the subsequent attacks there
seems to have been less spasm of the remote arteries than in the
first, and perhaps the cardiac plexus was more directly affected.
The feeling of impending dissolution assimilates the state a good
deal to angina. It is worth remarking that in this instance, as well
as in No. 102, there occurred the peculiar symptom of not daring
to sleep, and of the lower limbs feeling as if they did not belong to
the body. The apparent relation of the disorder to influenza, its
distinctly aguish character, and the occurrence of aguish bronchitis
at the same time in another member of the family are points of
much significance.

The remarkable case related by Dr. Stokes' seems to me to have
resembled the one just recorded. In the former, a rather mild case
of maculated typhus, the heart's impulse was strong and the sounds
remarkably distinct on the 8th day, and continued so until the 15th,
though no pulse could be perceived at the wrist. The surface was
icy cold, and of a violet hue, the countenance sunken, and the skin
and breath cold. Stimulants were of no avail. On dissection no
organic lesion of any kind could be discovered in any part of the
body ; the heart was firm and its muscular structure natural ; no
obstruction existed in any artery, but the whole quantity of blood
seemed much diminished; its consistence was somewhat pitchy and
its colour very dark. The wound made in the arm (for injecting
blood) was still gaping, and presented not the slightest appearance
of adhesion or inflammation. Knowing as we do how weak a con-
traction is sufficient to send a pulse-wave through open arteries I
cannot conceive that in this case the vessels were free from obstruc-
tion, and as no embolon, &c. was found at the autopsy it seems
pretty certain that they were occluded by spasm of their circular
coats, which naturally disappeared after death. This view is strongly
supported by the icy coldness of the surface, and of the breath,
phenomena which are rarely if ever observed except under such
conditions of the nervous system as exist during the algide stage of
fever. Had the failure of pulse been owing to cardiac debility, the
organ would not have been found firm after death, nor would stimu-
lants have been so ineffectual. The warm bath would probably have
been the best remedy, as it proved in a case to be presently men-
tioned. The observation is one of great importance as showing that
algide symptoms, the result of vaso-motor nerve irritation, may occur
in typhus fever. On talking this case over with Sir R. Martin he
made the sagacious remark that the patient must have had malarious
disease previously. Nothing is said about it, but it is highly probable.

* "Dublin Q. J. of Med. Sc," 1839, p. 7; and "Dis. of Heart and Aorta," p. 384.

CAKDIAC NEUROSES. 223

No. 105 — X. Z., m., fet. 37, had previously suffered from ague and from
recurring neuralgia, and had just returned from a malarious district. About
the middle of the day he was attacked suddenly with faintness, and after
taking some ether vomited. The syncope increased and became alarming,
requiring the frequent administration of restoratives and friction to the
surface. In the evening he had a dose of calomel and a rhubarb draught.
The night was sleepless, and the next day he was very prostrate, remained
in bed, unable to eat or to exert himself In the evening another attack of
syncope came on from which he was rallied as before. Ten grains of quinine
were now given, and early the next morning, ten more. He was feverish
in the night, but with an opiate had some sleep. The next day he was
better, had no faintness. From this time he gradually recovered, but was
unfit to work for some time. Several years have elapsed since the above
illness, but there has been I believe no recurrence, nor any indication of
disease of the heart.

Recamier cites two very instructive instances of the same cha-
racter as the foregoing. In the first, a man, set. 35, of good con-
stitution, felt some lipothjmic symptoms which soon ceased, and
recurred the next day at the same hour. No preventive means
were used, and in the third attack the man died. No adequate
cause for the fatal event could be found at the post-mortem. In the
second a young lady, get. 19, was affected in the same way, but
after the second attack bark was administered rapidly in full doses,
and she was speedily cured. Torti relates (Therapeut. Spec, p.
435) a case of syncopal tertian which appeared almost utterly des-
perate, but yet after the last rites of the Romish Church had been
administered the patient was snatched as from the jaws of the grave
by the use of bark. Hamilton mentions^ a case of " terciana syn-
copal" occurring in Peru. The subject was a negro, set. 40, with a
finely developed head who managed an estate for his master. He
■was as usual in the field in the morning when he fell on the ground
and was conveyed on a mule to his master's house in town. When
first seen after his arrival, he was more like a corpse than a living
man ; the pulse at the wrist was scarcely to be felt ; skin cold and
dry ; little or no shivering ; speech lost ; but his vision and hearing
appeared intact. The first thing done was to put the patient into a
warm bath, which seemed to operate as a charm, for the breathing
became freer, the pulse rose, and speech returned. After leaving
the bath the hot and sweating stages of the disorder appeared. It
•was ascertained that the bowels had been confined several days. He
was freely purged with calomel and rhubarb, took quinine and was
well in ten days. It is stated that such cases there are generally
fatal, and that those who are taken ill are given up for lost. Trous-
seau {CUnique Medicale, vol. ii. p. 763) mentions two cases in
which death seemed actually to have taken place, but which were
nevertheless restored by bark. Cardiac paralysis was no doubt the

1 Hamilton's "Practical Obs. on the Intermittent Fever of Peru." Highlev, 1842,
p. 27.

224 CARDIAC NEUROSES.

cause of death in some of the cases at Walcheran, of whom Sir G.
Blane says, " Under the influence of the endemial air recoveries were
slow and imperfect, and relapses very frequent, so that some of the
convalescents when apparently doing well would unaccountably
drop down dead. Slighter degrees of the same affection are I
believe by no means uncommon as sequelae of malarious fevers. In
a case of remittent fever under my own care the patient was at-
tacked one night by an alarming sensiition referred to the heart
attended with faintness and a failing pulse. He thought himself
dying, and said it seemed as if life was ebbing from him. After he
had become convalescent this cardiac disorder continued to recur
about every second day, and was especially induced by any painful
emotion or agitation. As the testimony of an independent observer
is of great value, I subjoin an abbreviated account of an attack in
which this same patient came under the observation of Dr. Symonds,
of Clifton. He was called one afternoon to see him in haste, and
found him, he says, in a rather puzzling condition. " There were
indications of some very distressing sensations about the precordia;
he pressed my hand against his side as if suffering some spasmodic
pain." He had complained the day before of pain in the heart.
" He was, however, so very delirious that one could not be quite sure
that the local feeling was not some delirious dysaesthesia. His pulse
was weak, small, not quick, hands and feet cool, head hot, eyes suf-
fused. He talked delirious of matters in which he had been engaged
some months before." Dr. Symonds doubted whether some decisive
remedies should not be applied to the head, but, guided by the state
of the circulation and the character of the neurotic symptoms, he
ordered for him brandy, a full dose of calomel + opium, Hoffmann's
ether and ammonia. Five hours later he was much better, quite
conscious, had passed an enormous quantity of pale limpid urine,
but still had pain in the region of the heart. " The case was now
clear — feeble heart, pseudo-angina pectoris, and a neurotic diathesis
heightened and disordered by the malarious influences to which he
had been subjected. With quinine, valerianate of zinc, creasote,
and opium, and occasional alterative doses of calomel, he was soon
convalescent." I was consulted in the case of a young officer, a
model of physical conformation, and apparently in good health, who
had been the cock of Eton, but after his return from India suff'ered
with such a distressing dyssesthesia referred to the heart that he
could not walk a mile without feeling that death was imminent.
There was nothing apparently wrong about the action of the heart,
nothing to be detected on the most careful examination. Yet I do
not think he was malingering, both from his serious alarm about his
malady, and from his not applying for any certificate to prolong his
leave of absence. Sir R. Martin informs me that cardiac debility,
as marked by an intermitting pulse is an extremely common result
of residence in India, and my own observation of returned Indians
has generally shown a markedly weak state of the circulation.

CARDIAC NEUROSES. 225

Whether this dehility aifect the nervous apparatus of the heart
solely, or its muscular tissue, or, as is most probable, both, I do not
undertake to decide. There can, however, be, no question that the
nervous system is principally implicated; no one can have had much
to do with malarious disorder without observing how large a part the
nervous system plays in the multiform phenomena that present
themselves. The treatment of these cases is in one respect plain
enough, viz., that they require invigorating tonic remedies, among
which we must always rate highly pure air and generous diet. But
in another respect, and that one which may be of momentous impor-
tance in perilous cases, our course is not so clear. Supposing in an
attack of cardiac angina of presumed malarious origin we find the
heart's action very depressed and we dread death from its failure.
This condition may arise on the one hand from irritation of the
sympathetic plexuses causing constriction of the coronary arteries
and so depriving the heart of an adequate supply of blood ; or it
may depend on a paralysis of the cardiac nervous centres and
nerves. In the first case sedatives would be needful, in the second
stimulants. The diagnosis must, I think, chiefly rest upon our being
able to ascertain whether or not the affection can be regarded as
coinciding with the algide stage of an intermittent, as marked by
the usual signs. If so, it is probable that the coronary arteries are
in a state of constriction, and we may either give opium with chloric
ether, and a warm bath ; or, if the distress is less urgent, wait till
the spasm spontaneously subsides. In the other case a large dose
of digitalis would probably be advisable together with free stimula-
tion. In doubtful instances it will be safest to give stimulants and
to apply an effectual mustard poultice to the precordia. This may
by its powerful excitation of the cutaneous nerves both arouse the
cardiac centres, and remove the irritation of the sympathetic plex-
uses. It sounds rather contradictory to talk of removing a state of
irritation in one set of nerves by setting up irritation in another.
Yet as a matter of experience it seems true that such may be the
case. The common practice with the laity of applying a mustard
poultice for the relief of all sorts of pain, including neuralgia, is not
so bad as at first sight it would appear. Duchenne, quoted by
Trousseau {Tr. de Therap.^ vol. i. p. 787), says, "It is a capital fact
that a sharp and sudden pain excited at any point of the cutaneous
surface possesses the property of modifying profoundly certain
sciatic neuralgias." The matter may be put in this way. When
we feel a pain, or have an irritation in any part, all that we can say
is that the nerve or nervous centre belonging to that part is in a
morbid state, which is generally functional and removable. Now if
we transmit through some other nerve a strong excitement of a
different kind to that centre we may succeed in abolishing the ori-
ginal morbid action, supposing it to depend on no actual organic
change. We all know how any matter that interests us much makes
us unconscious for the time of any minor disorder, and cases are on
15

226 CARDIAC NEUROSES.

record where a strong mental emotion has dissipated actual articu-
lar gout. The virtue of emetics in certain inflammations depends
on their action on the nervous centre of the inflamed part. In
giving opium in any case of cardiac affection we should be guided
very much by the degree of pain. Should this be severe, we may
give a moderate or full dose, ^ xxv — 1, but if the syncopal tendency
predominate, we should be very cautious in giving opium lest we
increase the depression. The good effect of the warm bath in
Hamilton's case was very striking. It acted no doubt as a relax-
ant, opening up the arteries and allowing the circulation to run
freely. Of course it should not be so prolonged nor the temperature
so elevated as to cause faintness. In the case of X. Z., No. 105,
on the contrary, I am much in doubt as to the exact state of the
heart, the general tenor of the phenomena was much more that of
direct depression and semi-paralysis of the organ than of arterial
constriction and ansemia. I have been the more inclined to notice
the point I have just referred to, as it has occurred to me in some
painful instances to observe the utter inefficiency of stimulants when
sinking had set in. Brandy poured down as long as the patient
could swallow had no effect. Of course I do not doubt the value
of stimulants in states of depression, but I cannot avoid posing
the question whether failure of cardiac action may not arise in
different ways, in one from direct paralysis of the cardiac nervous
centres and nerves, in another from irritation of the vagi or of the
medulla oblongata, and in a third from general arterial constriction
combined or not with a similar state of the coronary vessels.

The following instance of cardiac disorder was confidently referred
by the patient to the use of lead under his anvil, and he has had no
relapse since the lead was removed. I do not, however, feel abso-
lutely convinced that the case was one of saturnine intoxication, as
the gums presented no blue line, but I think this is the most prob-
able view. Lead was found I believe in a quantity of powder
removed from under the anvil.

No. 106. — J. R., get. 28, a hearty man, ad. Dec. 27th, ill fourteen days.
Was attacked between twelve and one at night while asleep with great pal-
pitation and giddiness, great weakness and sense of illness; has had palpita-
tion more or less ever since. No bruit about the heart, nor enlargement,
its action is excited. Lungs healthy. No dyspepsia. T. coated, clammy ;
bad taste in mouth ; some thirst. No epigastric tenderness. Was quite
exhausted by walking about two miles to the hospital. States that he works
as a smith at an anvil beneath which is a piece of lead to deaden the sound,
which lead gets cut up into dust and gets into his throat. His employer
affirms that men have been destroyed by this kind of dust. He has been
exposed to the action of the lead four months. He was ordered strychnia,
iron, spt. aeth. S. Co. and henbane, and improved, but on returning to work
found that "it almost killed him." There was then slight paralysis of two
fingers of the right and of one of the left hand. Is pallid, nervous, weak
and tremulous. He was now (Jan. 6th) ordered ammon carb. -j- tr. nuc.
vom. + tr. opii ttlv ex. inf. gent. co. ter dicj with ferri carb. saccht., under

CARDIAC NEUROSES. 227

whict he nearly recovered in a month and was at work (without the lead)
the last week.

Mr. Pye Chavasse records^ a remarkable case of great nervous
prostration with right side anaesthesia, anxiety, and palpitation of
the heart (which was sound) on the slightest exertion, which seems
certainly to have been occasioned by the use of water impregnated
with lead. " The blue line on the gums if not altogether absent
was at all events very faint." In my own case, as in Mr. Chavasse's,
it is a strong point in favour of the lead poisoning view that the
patient recovered so completely after removal of the presumed cause.
Had it been otherwise, had he suffered from foul air, general de-
bility, influenzal miasm or any other depressing cause, he would have
been much longer in recovering, and would in all probability have
relapsed. He is now strong and hearty. In such cases the cardiac
nervous centres seem to be directly affected, to be semi-paralyzed.

No. 107.— A. R., f , set. 26, ad. Jan. 22, 1858. Complexion florid, has
lived in London last twelve years. Subject to rheumatism last nine years,
suffers from it every winter. Had rheumatic fever nine years ago, has had
palpitation more or less ever since, but not to such an extent as to cause
her alarm till three months ago. Action of heart very tumultuous, com-
plains of constant pain in the region of heart of dull wearing character,
increased when palpitation comes on, which it does several times a day,
especially on the slightest exertion. Has pain in knees increased at night,
a little dry cough in the morning. Thyroid gland enlarged equably; it first
enlarged six years ago, is now less than it has been. Evident proptosis. P.
very small. Breathing natural. B. costive, Feb. 11th. Heart beating
with considerable violence, extended dulness over precordial region more
especially at right side. Complains still of pain, gets but little sleep. A
blowing sound is heard all over the heart, but a distinct rough systolic bruit
is heard in the second intercostal space immediately to the left of the sternum j
a thrill is also felt here. Same bruit is heard over right carotid. To the
right of sternum both aortic sounds are heard clear. Health greatly im-
proved. 22d. Pain very severe last night and palpitation increased, no
sleep. March 4th. Pain not nearly so severe, and referred entirely to one
spot near the apex of the heart. P. 112. T. clean. Less proptosis, goitre
decreasing. March 12th. A severe attack of pain and palpitation last night
relieved by empl. bellad. c. opio. March 18th. Much improved. 19th.
About middle of day became worse with increase of pain, and severe vomit-
ing ; the latter was allayed by hydrocyanic acid and digitalis in effervescing
salines, but the pain continued very severe till 8 P. M., when eight leeches
were applied to the precordia; she expressed herself as much relieved, but
died the following morning at 7.30. She was leeched over the heart on Jan.
25th with relief, and blistered about the same part on Feb. 9th, 22d, and
March 1st, with some advantage. She took small doses of tr. digitalis, spt.
ammon. foetid., sal volatile, and tr. ferri ammon. Her P. was generally
about 120. Poat-mortem — Bronchial and cervical lymphatic glands en-
larged, supra-renal capsules, liver, spleen, kidneys healthy. No pericarditis.
Heart of normal size, its valves effective, some vegetations on the mitral, its

1 "Brit. Med. J.," April 23, 1869.

228 CARDIAC NEUROSES.

muscular tissue of good colour. Both lungs in a state of pneumonic en-
gorgement, the left at posterior part grajly hepatized. Thymus gland very
large, weighed 1,200 grains; it overlapped the pericardium, lay upon the
aorta and pulmonary artery, and reached down to root of left lung. Thy-
roid gland much enlarged. Brain healthy.

The symptoms in this case indicate the existence of a primary
neurosis of the vagi nerves of a paralytic kind. The phenomena
bear considerable resemblance to those produced by division of these
nerves. The excited quick action of the heart is a constant result
of this operation, and after death the lungs are often found more or
less engorged and condensed. The attack of pneumonia which so
suddenly supervened and so rapidly proved fatal was probably the
result of some casual catarrhal (influenzal) agency affecting a system
highly predisposed to pulmonary congestion and consequent effusion.
Budd^ and GulP have both noticed the occurrence of low or gan-
grenous pneumonia from the compression of the pulmonary nerves
by tumours of various kinds. The slight anatomical change found
in the mitral valve is quite insufficient to explain the pain and pal-
pitation which so frequently recurred. It seems impossible to regard
them as other than functional disorders, especially as they varied so
much. How far they were dependent on injurious pressure exercised
on the vagi nerves by the enlarged glands must remain uncertain,
though my belief is that no such pressure existed. I have certainly
seen cases with very much greater glandular enlargement where no
such symptoms were present. The thyroid enlargement and the
proptosis are difficult to account for satisfactorily ; but the common
occurrence of goitre as the result of malaria indicates its dependence
on the vaso-motor nerve paralysis and consequent hyperaemia, and
the same conditions were probably concerned in inducing the prop-
tosis. Thus if we suppose hyperasmia of the tissues contained in
the orbital cavity to issue in serous effusion, which is no very un-
likely event, the globes would be protruded. I have at the present
time two cases under my care which exemplify the influence of
hyperaemia and serous effusion in causing this condition. In one
where the proptosis has supervened quite recently, there is strong
pulsation of the carotids, pain in and behind the globes, tension of
the lids and great congestion of the conjunctiva. The patient is
epileptic. In the other the proptosis is of old standing, there is no
tension or redness of the lids, but there is a quasi-oedematous swell-
ing all round the orbit, an evident pushing out of the integument.
Pressure on the eyeball does not cause it to retire much into the
orbit, but it certainly makes the bulging integument more tense. In
this case there is serous effusion, in the former congestion. It is
possible also in some cases that an enfeebled state of the recti
muscles contributes to the proptosis. Eor further remarks on this

1 "Med Chir. Trans.," 1859, vol. xlii. p. 215.

2 u Guy's jjosp_ Reports," 1859, p. 307.

CARDIAC NEUROSES. 229

subject I may refer to a highly interesting case published by me in
the Med. T. and G-az., Jan. 2d and 9tb, 1864. In this though
cardiac symptoms were not so prominent there was extreme debility,
cough, and gastric disturbance, which brought life into very con-
siderable peril. Under sedative and tonic means she was quite
restored excepting the goitre. It is abundantly clear from the pre-
ceding cases that an affection of nerves supplying vital organs may
be a very serious thing, and that the prognosis should in such cases
be guarded.

A common form of cardiac neurosis is that where the action of
the heart is much accelerated, ranging from 110 to 140 in the
minute, in the standing position, and not falling much below the
former figure in the sitting. The contractions are abnormally sharp
and vivid, the organ seems to spring up with a quick forcible leap
against the ribs. The apparent excess of action misleads the prac-
titioner sometimes to suppose that there is hypertrophy. Percussion
however shows that no enlargement exists, and auscultation detects
no vascular bruits, nor derangement of the rhythm. The feeble
stroke of the radial pulse often contrasts markedly with the vivid
action of the heart. The general condition of the patient exhibits
more or less evident indications of debility. Dyspepsia is often
present to some extent, but is by no means always the essential
cause. Tea on the other hand seems in some cases really to be the
" fons et origo mali," the symptoms subsiding materially on its
omission. I think the pathological condition in such cases is essen-
tially hypersesthesia either of the nervous centres or of the sensory
nerves of the heart, perhaps especially of those fibres distributed
to, the endocardium of the ventricles. The hypersesthesia is as in
other instances the result and associate of debility. The feebleness
of the pulse shows how ineffectual the apparently forcible contrac-
tions of the heart are. In fact the ventricles do but grasp the
blood for a moment, and relax again immediately before they have
fully emptied themselves. A case at present under my care illus-
trates well how much more efficient a slower and more sustained
action may be. An elderly man complains only of lassitude, has no
dyspnoea, no indication of defective circulation. He is anaemic,
but has no nerve disorder whatever. His pulse when first seen was
only 20 ; there was scarce any impulse to be felt, the sounds were
indistinct, and similar to each other. With iron and ol. morrh. the
pulse has risen to 32, and he has become stronger. In this man it
is evident that the heart contracts steadily and quietly on the blood
in its cavities and expels it fully. There is no spasmodic jerk in the
contraction, and consequently no notable impulse.

Dr. Lyons^ has recorded a remarkable case which is as follows.
A male, between 30 and 40 years of age, began to suffer at first
with debility and unpleasant sensation in the chest ; after a time

I "Dublin Q. J. of Med. Sc," May, 1862.

230 CARDIAC NEUROSES.

could not leave his room, and scarcely could stir without increasing
the heart's action. During the periods of excitement of the heart's
action the debility was extreme, the patient's sufferings most intense,
and the cardiac action almost more violent and tumultuous than
Lyons had ever before witnessed. The face was flushed vividly, the
pulse was 120, regular, and not remarkable for force or volume.
The impulse was very violent, and a loud, diffuse, systolic bellows
murmur was audible with great and equal intensity over the whole
precordial region. Iron and tonics failed to give any relief, but
vesication continued for ten months was of some service. After
about five to seven years he completely recovered, and the most
careful examination was unable to detect anything in the least de-
gree morbid about the heart or any other part, Lyons considers
this case to have been one of pure uncomplicated myocarditis. To
me it appears more probable that it was an intense neurosis of the
above kind, for these reasons : I cannot think that a myocarditis
could exist for years without destroying life, or at the least seriously
damaging the tissue of the heat, or of its valves by extending to
them. Moreover an inflammation would so weaken the muscular
fibres as to prevent the action of the organ from being excessive.^
On the other hand the extreme debility, the intense suffering, and
especially the long continuance of the disorder are much in favour
of its neurotic character.

The treatment of cardiac hypersesthesia is too often unsatisfactory,
probably because it is impossible to obtain rest for the organ. An
irritable brain or stomach may be soothed by giving them timely
repose, but we can do this but very partially with the heart. Avoid-
ance of all emotion and excitement is very desirable, and the diet
must be scrutinized to see whether some of its component articles
may not produce or increase the hypersesthesia. In severe cases
occasional small leechings may be recommended. Belladonna plas-
ters are generally useful, and I should expect benefit from hypo-
dermic injection of opium into the precordia. Internally I have
seen most benefit from tr. digitalis, "Ixv ter die, but I am not al-
together satisfied how far it is quite safe to give this drug in states
of cardiac excitement. In conditions of cardiac languor I have no
fear of it, but in the opposite I think we need to be cautious. In
some cases aconite and hydrocyanic acid may be useful, but they
have not served me well. Opium and nitrate of silver might be
suitable remedies, especially where there was irritable dyspepsia.
The very possible dependence of the disorder on some remote, per-
haps little heeded, irritation should not be forgotten.

' Demme states that the most constant and manifest symptoms of myocarditis are
decrease of the heart's energy, loss of rhythm in its movements, increasing frequency
of the pulse, steady diminution of its size, and its continuous undulattry character. —
V. "Schweiz. Ztschr. f. Heilk.," i. pp. 79, 46J ; 1862.

EESPIRATORY NEUROSES. 231

CHAPTER XXVIII.

RESPIRATORY NEUROSES.

The pulmonary enjoy no exemption from the disorders which are
apt to befall other nerves. Some of their neuroses have long been
accepted as classic diseases. I purpose to notice some of the more
practical points relating to different typical forms, founding my
remarks on cases of actual occurrence.

No. 108.— M. T., f., set. 27, ad. Oct 13th. Ill six days. Complains
that she can't get her breath, can't sleep at all soundly for dyspnoea at night.
Her chest is not tight, she has no cough, air enters freely into lungs ; sounds
of heart normal. P. good. Has cold perspirations frequently. Menor-
rhagia exists to some extent, the catamenial flow lasts seven to fourteen
days. Feels faint and giddy. Takes food fairly well. With ferri carb.
saecharata, ammon. carb. and tr. arnicae and liq. pot. arsen. she improved
materially during the six weeks she attended ; the last time I saw her '' her
breath was nothing near so bad."

No. 109. — Master H., set. 9, seen December 9. A fair-haired, intellec-
tual-looking, lively boy. Ill for more than a year. Is decidedly feverish
and is thirsty at night, not by day. Is frequently sighing deeply, about
once a minute or oftener; this " besoin," he says, keeps him awake at night.
The lungs and heart are quite healthy. He has pain also in the abdomen
about the upper and mid-part, not increased by pressure. Appetite bad.
Tongue clean. Skin cool. Pulse weak. With quinine + iron he recovered
completely.

Remarks. — In both these cases the phenomena seem to be referable to a
semi-paralysis of the pulmonary branches of the vagi, a sort of anaesthesia
in consequence of which the reflex inspiratory actions could not be per-
formed with their normal facility, but required the assistance of volition.
Debilitating disorder was present in both instances, viz., menorrhagia in the
female, and obscure nocturnal remittent in the boy. The good eff'ect of
nerve tonics was very marked. As under these the general power was improved,
the ansesthesia yielded. In contrast with these I may cite some instances
of an opposite kind.

No. 110.— E. C, f., aet. 52, ad. January 29th. Ill eight months with
severe catarrh and cough, pains between shoulders, dyspnoea, anorexia.
The cough is very violent but dry. No rales heard on ausculting the chest.
Is very weak. Atropise gr. yi'o + tr. ferri mur. Tt\^ xv + oxym. scill.
TTL XV -{- aq.^jterdie. February 12th. Cough very much better. Strych-
nia with tr. ferri mur. was now given, and the atropia omitted. 19t.h.
Wonderful appetite from this medicine, but it does not quiet cough like the
other. Pt. addendo atropise gr. j^^ ad. sing. dos. The cough was soon
relieved and she was discharged March 12th.

No. 111.— W. M., m., get. 59, ad. April 12th. Ill all the winter with
cough, but not enough to lay him up ; worse last six days. Gets weaker

232 RESPIRATORY NEUROSES.

and weaker; can't work now. His breath fails on exertion. Much thick
expectoration. No rales in backs, breathing obstructed in right front,
' fairly good in left. No sleep at night from cough. When he has an attack
of cough it affects his head so that he falls off the chair and becomes insen-
sible for a minute ; this often occurs at the instant the cough comes on.
Appetite very bad. Vomits up his food at times. P. large, soft. Skin
cool. B. open. Lungs rather emphysematous. During the treatment he
experienced for a time a sensation in his head as if he was half stunned,
making him feel stupid; this was relieved by putting his feet in hot water.
His treatment consisted of strychnia, nitric acid, and opium with morphia
and stramonium at night, subsequently of quinine and arsenic. He bene-
fited very decidedly, and- was cured in less than a month.

No. 112. — D. P., f., set. 42, ad. December 17th. Of short broad make.
Ill two to three weeks with a dreadful screaming cough, which causes much
trembling and exhaustion, and lasts for four or five hours at once. The
cough strains her chest so that she fears that some extensive cicatrices on
the chest from erysipelas, which she had last year, will give way. No in-
sensibility ever induced by cough. Pulse of good force. T. clean. Urine
copious, thick. No appetite. Always very weak since her illness. She
was ordered acid, nitrici ni iij + atropiae gr. ^^^ -f aq. §j quater die.
This was taken up to January 18th, the doses being increased in number up
to seven or eight a day. It produced very considerable improvement both
in the cough and expectoration, and was then changed for quinine + iron
-f liq. opii sed. ni^vij quater die, with which she improved still further,
and the cough completely ceased.

No. 113. — Gr. F., m., set. 28, seen November 15th. Ill one month, never
suffered in same way before. Of very stout plethoric habit. Pulse 100,
soft, large, not notably weak. Heart's sounds normal. Urine lateritious.
Suffers from a severe cough, paroxysmal and suffocatory, attended with sub-
sternal pain ; it occurs in a succession of expiratory acts like the cough of
pertussis. Cannot lie down at night. Is easy sitting in a warm room, suf-
fers much more on exposure to cold. No rales in chest. His mother states
that he never had hooping-cough, and it is prevalent in the vicinity.
There is a good deal of blood in the mucous expectoration. With nitric
acid, strychnia, quinine and opium ter die, and stramonium and morphia at
night he improved rapidly, and in a week was convalescent.

Remarks. — These cases are examples of a not uncommon pulmonary
Deurosis, in which together with marked general debility, and more or less
local vascular congestion there exists predominating hypersesthesia of the
nerves of the air-passages. When the hyperaesthesia is considerable, and
there is but little catarrhal affection, atropine has approved itself a very val-
uable remedy. If there were much vascular congestion I should prefer
opium. Where the debility is great strychnia and iron, aided usually by
the sedatives, should be employed ; they seem by imparting tone to lessen
the undue excitability of the nervous structure. The peculiar attacks of
insensibility which occurred in No. Ill were not, I believe, at all dependent
on congestion of the brain, but rather on a spasmodic contraction of its
arteries, such as we suppose to occur in the " petit mal" of epilepsy. They
ceased under the tonic treatment together with the cough.* I look upon

' In a patient under my care with pretty severe bronchitis attacks of insensibility-
sometimes occur when he has coughed less than half a minute, so complete that he
has fallen down and hurt his face, while at other times he coughs for a long while
without losing consciousness.

RESPIRATORY NEUROSES. 233

tbem as analogous to the cerebral disorder which a gastralgic patient re-
cently under my care complained of. He stated that the pain made hira
light-headed at times ; he felt as if his senses were going away. He was
cured by strychnia, iron, and opium. In this case there could be no ques-
tion of any cerebral congestion. ^

Pertussis is of course the capital example of a specific bronchial
hypersesthesia. The excitement of the vagi nerves, however induced,
is clearly peculiar and not identical with that just noticed. It is
consequently much less under the control of remedies. I do how-
ever by no means agree with Romberg that treatment is so ineffec-
tual as he seems to consider it, and I believe that most physicians
still retain faith in the utility of j'arious measures. Dr. Whitehead
has adduced^ evidence showing now much the duration of the dis-
ease can be diminished by treatment. Thirty-five cases not treated
till the disease had lasted three months were cured on an average
in less than twenty-five days; and eighty-seven whose treatment was
commenced within fourteen days after the onset were cured in the
same time. Opium, usually as Dover's powder, and belladonna were
the principal remedies. Trousseau, referring to Bretonneau's treat-
ment of the disease by belladonna, says,^ "Nous avons pu nous-
memes constater I'extreme efficacitd de ce moyen," and Vollant^
affirms the same in the strongest terms. The latter uses only the
powder of the root, which he gives in doses of gr. i, increasing the
number from one to four or five a day till the paroxysms begin to
subside, when it is given less frequently.

Dr. West confirms to a great extent Dr. Hamilton Roe's testimony
of the efficacy of prussic acid, and has only in one instance out of
many hundred known any actually poisonous effects to be produced
by it. _

The evidence for the real remedial power of this drug is worth
considering, and our conclusion in its case may be applicable to
others. Its sedative effect in some gastric hyperaesthesias cannot
we suppose be questioned. It may therefore be admitted that it
acts as a calmative to the filaments of the vagi distributed to the
stomach, and consequently it is very probable that it will affect in
the same way those which proceed to the lungs. An unbiassed and
thoroughly reliable observer as Dr. West, tells us that in some cases
it " exerts an almost magical influence on the cough," while in other
cases it seems perfectly inert and sometimes injurious. Does not
this warrant our regarding hydrocyanic acid as a remedy which may
serve us well, but may also fail us, and forbid our rejecting it alto-
gether ? Moreover there is some ground at least for believing that
it is not a matter of indifference what preparation we use. Much
of the variability in the results obtained from this as well as from

> "Third Report of Clinical Hospital for Children at Manchester, 1859."

2 "Traite de Therap.," vol. ii. p 71,

* "J. de Med. et de Chirurg. Pratiq.," vol. xxxiii. p. S61.

234 RESPIRATORY NEUROSES.

other remedies depends no doubt on the dissimilarity of the prepara-
tions employed in diiferent instances. We have just seen that
Vollant lays stress on the use of belladonna root, deeming the leaves
to have little efiScacy. Hepp insists on the importance of carefully
following Withering's directions in collecting and preparing digitalis.
Not more than a year's supply he says should ever be kept. Is it
not pretty nearly certain that nearly worthless drugs are too often
employed ? Bearing in mind the above, I am not at all shaken in
my belief of the utility of treatment by finding that a great variety
of remedies have been found or considered capable of arresting or
diminishing the disorder in some instances while they have entirely
failed in others. This, even admitting the purity and equal virtue
of the preparations, as I have already observed, is a feature, common
to many disorders and especially to neuroses. The idiosyncrasy of
the individual patient, and the existence of numberless shades of
difference in the nature and quality of the morbid processes are
quite sufficient to prevent our remedies from having that certainty
of action which many look for, and not finding become sceptical of
all therapeutic agency. Even with regard to non-specific bronchial
hypersesthesia after considerable experience I have no certain fore-
knowledge as to whether atropia, opium, or cannabis indica will be
successful in a given case. I am quite ready to charge some of this
uncertainty to my own want of discernment, but I am certain that
cases are not uncommon where the symptoms are to all appearance
quite the same and yet the same remedies will have very different
effects. One of the chief mistakes current at the present day is to
regard all diseased states to which the same name can be applied as
exactly and essentially similar, whereas the truth is that the same
name covers a multitude of morbid conditions which vary ad infini-
tum in their component elements. The gross, outward resemblance
leads us to overlook and neglect the concealed but more important
differences. This is the more to be regretted as the latter rule the
treatment.

With regard to pertussis I am much inclined to regard hydro-
cyanic acid as suited to an earlier period of the disease than atro-
pine is ; I give it during the catarrhal stage with vin. ipecac, and a
saline. Combined with nitric acid it is very suitable also to a later
period when the catarrhal affection is less acute, the dry have given
place to moist r^les, and the febrile movement has subsided. When
the cough is very violent and the catarrhal affection is slight I 'ex-
pect great benefit from atropine. I have however seen it in combi-
nation with nitric acid act exceedingly well in an infant suffering
with severe bronchial catarrh complicated probably with miliary
tubercle. As to the objections raised by some against employing
such potent agents especially in young subjects I think it may be
fairly replied that medicine cannot be practised at all without care
and attention, and a very moderate amount of these is quite suffi-
cient to prevent the possibility of any injurious consequences from

PERTUSSIS. 235

the administration of any of the alkaloids. It may be affirmed that
atropia is actually safer to use than opium. The latter, if an over-
dose is accidentally taken, is more likely to be lethal than atropia,
unless indeed the dose is very large. In the convulsions occurring
in severe hooping-cough I have found atropia of some benefit, but
not of so much as I had expected. I am doubtful at present whether
opium is not preferable. The following case is a good example of a
combined treatment which will be suitable in many instances-
No. 114. — A. S., f., set. 7, ad. Nov. 12th, ill two months with hooping-
cough ; in mornings has hard strangling fits of coughing after which she
brings up about 5ij of blood. Some shght large-tube rales in backs. Takes
food fairly. Has about twelve fits of violent cough in twenty-four hours.
P. weak and soft. T. dark mahogany coloured in morning. Atropiae gr.
y^o + acid, nitric. TT\^ij + aq. ^ss ter die. 26th. Is quite a difi'erent child,
cough a great deal better, does not spit any blood now, or complain of her
head. Pt. c. m\s,t. siihinde. Dec. 30th. 01. morxh. '^] ter die ; vini ferri
5j ter die. 14th. Recurrence of cough. Reptr. mistr. atropiae. 31st.
Better, does not cough so often, but has violent attacks now and then. Pt.
Jan. 11th. Does not whoop now at all, but has very bad cough at night for
one hour. Ferri et quin. citrat. gr. v ter die. Pt. c. oleo. 25th. Cough
nearly gone.

Bromide of potassium has lately been given by several physicians
with very good results. From two to five grains is the dose for a
child from two to five years old. Bromide of ammonium may be
used in the same way.

The affection termed laryngismus stridulus, or spasm of the glottis,
is one of peculiar interest, not only as a well-marked instance of
nerve disorder capable of receiving a satisfactory explanation from
established principles, but also on account of the great peril to life
attending it. The child which but a minute before appeared toler-
ably well may the next be laid lifeless in its parent's arms. The
suddenness of the stroke which we know may fall at any moment
adds much to the painful interest with which we must regard these
little patients. The two following cases will serve as a text for some
comments.

No. 115. — A. R., m., set. 2, ad. April 6th, ill two months. Has had
from the first attacks of convulsive character, apparently consistin'g of laryn-
geal spasm. A baby belonging to the same mother was attacked last week
suddenly and died immediately. This child had the disease when 8 months
old, got better during the summer, but has been worse the last winter. Has
some cough, varies much, some days the attacks occur every hour. B. open.
T. much coated. Lives in a kitchen. Is a very weakly child, does not
walk. Two upper incisors are just making their way through the gum
(lanced). The condition of the alimentary mucous membrane was corrected
by small doses of gray powder and olei ricioi, and ferro-citrate of quinine
was steadily administered for nearly eight weeks, during which he was taken
out into the open air. Under this treatment he improved so much that he
ceased attendance by the end of May. No relapse occurred or none of im-

236 RESPIRATORY NEUROSES.

portance till the beginning of the following November, and then the repeti-
tion of the same treatment together with ol. morrh. proved curative.

The relation of the disorder to dentition in this case was not at
all well marked, nor was there any other apparent exciting cause.
I believe the nervous centres were more at fault than the peripheral
structures. The tonic probably arrested the disorder by lessening
the excitability of the medulla oblongata. The weakly condition of
the little patient was presumably the cause of the morbid state of
this centre. The nervous erethysm was neurolytic.

No. 116. — Gr. H., m., set. 10 months, seen Jan. 17th, 1861. Is suffering
severely with attacks of spasm of the glottis which occur about every twenty
minutes. The affection commenced gradually with very slight attacks six
weeks ago; it has been much worse during the severe frost. About sixteen
days ago he had a well-marked convulsive seizure which has not recurred
since. In the attacks he first turns pale, throws his head back, the commis-
sures of the lips are drawn backwards in a kind of grin, the face becomes
sub-livid, there is a period of silence, and then comes the peculiar stridulous
inspiration, which recurs several times, and is followed by a natural cry.
He is greatly depressed, his face looks sunken, he seems ill and rather
emaciated. B. rather costive. No fever. Is teething and has had the
gums lanced twice or thrice, but the last time it appeared to be of no benefit.
Until lately has been a remarkably placid and healthy infant without any
tendency to diarrhoea. He has been brought up by hand. Three or four
times a day he takes small doses of ol. ricini -f- ol. terebinth., besides ferri
carb. sacch., and a small opiate at night. 19th. This afternoon he had a
sharp attack of convulsions, and during the whole evening and early part of
the night had frequently glottic spasms, and was crying with pain. Chlo-
roform was repeatedly administered and with good effect in tranquillizing
him, but its influence soon passed off. After taking vri\j of liq. morph.
bimec. he was quieter and slept. 21st. Yesterday began to take extr. bel-
ladon. gr. xV + ol. tereb. TTLiij ter die, had morphia in the night; is on the
whole quieter ; a second dose of liq. morph. bimec. tTLiij was given to-day.
B. open. 24th. Last two days is decidedly better, taking little but the
morphia, the attacks of glottic spasm are much less frequent and severe, but
diarrhoea has begun, the bowels which before were costive being loose and
gripy and the stools green. 28th. Worse last three days, has severe and
frequent attacks ; great restlessness especially at night and suffering evidently
referred to the mouth; the gums look natural. He takes tr. bellad. ttliv-v
2dis vel 4:tis horis. 29th. The belladonna entirely failed to give relief,
although it evidently deranged his vision ; he has to-day been taking liq.
morph. bimec. in ttl four doses bis vel ter die, and is now quieter. Takes
very little food. 31st. Is better and has less attacks, takes morphia. Feb.
4th. Is very much better, the attacks of laryngismus have ceased. 7th.
Going on well, no medicine. 18th. Has had a little return of the laryn-
gismus, but not material ; is otherwise fairly well. March 9th. Has still
the laryngismus occasionally, but is doing well, gaining strength ; takes
morphia daily. 18th. Had yesterday some very severe attacks. April 18th.
Numerous and severe attacks of laryngismus lately, and this morning a fit
of convulsions, in which his face was markedly pale. The upper lateral
incisors are now advancing, but the gums do not appear tense or red (lanced).
After this the attacks gradually ceased. Nov. 21st. At the beginning of

LARYNGISMUS STRIDULUS. 237

June he went into the country where he remained about three months, and
returned quite restored. He is now cutting his first molars, and though he
has had some catarrh there has not been the least return of the laryngismus.
Jan. 1864. No return of the disorder, the child has thriven well.

The relation of the disease in this case to dentition is by no
means clearly established. It certainly supervened about the com-
mencement of the process, but it subsided long before it was over,
and the aggravations of the disease did not evidently correspond to
the period of eruption of a tooth. Whether there was some deep-
seated irritation connected with the development of the teeth can
only be conjectured ; if so, it only existed during the formation of
the earlier teeth. The three points which the history seems to set
forth prominently are, (1) the connection between the disease and
general convulsions ; (2) the good effect of morphia and the inutility
of belladonna ; (3) the importance of change of air. The occur-
rence of general convulsions in connection with laryngismus indi-
cated that the morbid action extends to and involves some larger
group of nerve cells than in the local spasm, probably either the
whole of the medulla oblongata, or the corpora quadrigemina also.
The convulsions as well as the glottic spasms appeared to depend
much more on a state of erethysm of the nervous centres than on
any peripheral irritation. I mean that the former was much the
more important causative element, the removal of which would have
arrested the morbid phenomena. This is evidenced also by the
" juvantia," sedatives affording relief, while lancing the gums had
no decided good effect. I am much inclined to refer the superven-
tion of the disorder to the severe cold of the winter which depressed
and deranged the " vis nervosa." The first attack of general con-
vulsions occurred during a hard frost. In this instance as in some
others it has certainly appeared to me that the prevalence of severe
cold has materially promoted the occurrence of general convulsions.
The cold seems to depress the nervous power of the little patients,
and make exciting causes of disorder more operative. The inference
from this is that the child should be kept during cold weather in a
well- warmed room, at a uniform temperature say of 64 deg. F., and
that this should be maintained night and day. The sudden death
which is by no means uncommon in this disease depends I conceive
on the transmission of irritation along the cardiac fibres of the vagi
to the heart, which is then arrested in its action just as when the
pneumogastrics are strongly galvanized. Life truly hangs by a
thread while we know not whether in any one of the attacks the
nerve disorder may not take this fatal direction, instead of invading
the recurrent laryngeals only. The superiority of morphia to bella-
donna was unequivocal, a result which was not anticipated, on ac-
count of the greater tendency of opium to cause tetanic phenomena.
It is very possible that in another instance the result might be
different, but it is as well to remark that in the fatal case of epileptic
disorder recorded at p. 51 the attacks subsided under the adminis-

238 RESPIRATORY NEUROSES.

tration of morphia. The doses given were certainly large, the
strength of the bimeconate being about equal to that of tr. opii ;
they produced however no trace of narcotism. This shows that the
erethysm of the centres must have been considerable. The car-
bonate of iron which was tried was certainly of no benefit, if not
injurious. This result contrasts strongly with the good effect of
tonics in the other case. It may be accounted for I think by ob-
serving that the subject of the first case was a very weakly child,
while that of the second was the reverse. The condition of the
latter was more sthenic than that of the former. All this corrobo-
rates what has been before said as to the difficulty of determining
exactly the remedy suitable to an individual morbid state, and shows
how the self-same symptoms may result from difi"erent pathological
conditions. The attacks had indeed ceased before he was removed
into the country, but the great improvement which ensued in his
health makes it eminently probable that his subsequent immunity
depended on the calming and toning influence of the purer air.
Considerable intermissions had previously occurred, but had been
followed by relapses. Romberg writes respecting the free intervals,
" the first thing to attend to is the atmosphere and the diet." This
is quite my own feeling, and indeed in all neuroses attended with a
high degree of sensitiveness and excitability, and not depending on
an eccentric cause, I look to the influence of a pure rather bracing
air as the most sovereign remedy. Tonics are apt to prove too irri-
tating and sedatives to lose their efficacy.

In an able paper on this disorder (v. Brit. Med. J"., March 7th,
1857) Mr. T. Paget lays down the following directions for treatment
with which to a great extent I concur. After removing all peri-
pheral causes of irritation, whether dental, intestinal, or elsewhere
seated, he contemplates the subjection of nerve excitement by means
of narcotics as the most important object. " Upon the narcotic to
be used, upon the mode of giving it, or the dose required, I need
lay but little stress, especially since it is well known how varied is
the susceptibility of individuals in reference to this class of medi-
cines. Suffice it to say that the drug I have most used is opium ;
that beginning with small doses and cautiously regulating them
according to their efi"ect, I do not stop short of producing a constant
drowsiness and some slight pallor, that when this state is obtained,
the paroxysms decrease in force and frequency, the infant is calmly
sleeping its day away, no longer devil-torn, nor are its friends racked
with anxiety ; and that when the paroxysms have failed to occur for
some forty-eight hours, which will usually happen in from three to
six days, the drug is gradually withdrawn, the quantity taken off
each dose being immediately restored if the attacks show the slightest
disposition to encroach again. I may say also that to attain to the
required effect I have usually been obliged to give to children 4 or
5 months pld (the age at which the disease most commonly perhaps

ASTHMA. 239

invades) from 1 to 5 minims of tr. opii in a dose with 4 or 6 of sal
volatile two or three times a day ; or if in enemata 5 to 7 minims."
Asthma is by general consent acknowledged to be essentially a
neurosis, though it is rare to meet with it in a pure form. Usually
it is attended with more or less of bronchitis just in the same way
as retinal hypereesthesia is with conjunctivitis, while spasm of asso-
ciated muscles is a prominent feature in both cases. The view
usually taken of the special seat of the neurosis is that it affects
those branches of the vagi which are distributed to the bronchial
muscles, and that the latter being spasmodically contracted seriously
obstruct the access of air to the cells of the lungs. It would be
expected according to this view that the chest would be rather
diminished than expanded in size, and such appears to be actually
the case. That excellent observer, Dr. Walshe, states that there is
sinking of the epigastrium, and elevation of the diaphragm (evi-
dently from the diminished mass of air in the lungs). Dr. Flint^
says that " if emphysema be not present, the volume of the lungs
may be so reduced by the expiratory efforts as to diminish appreci-
ably the clearness on percussion." It appears however that this is
not a constant and invariable condition, but that it may be replaced
by the opposite. Wunderlich^ describes one form of asthma as
consisting in a gradual augmentation of the dyspnoea which reaches
its maximum at the end of two or three days. At this stage the
chest is almost motionless in spite of the most violent muscular
efforts, the percussion resonance is everywhere preserved, and after
many hours the limbs of the chest are extended downwards. The
liver also descends, the heart is thrust into the epigastrium, and the
thorax is excessively distended." Thdry^ also describes the thorax
during the paroxysm as being in a state of the greatest distension,
as in forced inspiration. The diaphragm however contracts some-
times so forcibly as to depress the lower end of the sternum back-
wards. Kidd^ and Sanderson' describe this state of great distension
as that which is characteristic of asthma, though they differ as to
the mode of its production. The former refers it to a tonic spasm
of the muscles of inspiration ; the latter to a relaxation of the
dilator muscles of the glottis, as well as of the contractile fibres of
the lung tissue, in consequence of which expiration cannot be
properly performed. There can be I think little doubt that the
view held by the two last observers is too exclusive, and that except
in cases complicated with extensive emphysema there is no notable
if any dilatation of the chest in the earlier part of an attack of
pure nervous asthma. That in the course of a prolonged fit the
chest should become distended is quite intelligible if we consider
that the inspiratory power is much superior to the expiratory, and

I '^On Respirat. Organs," p. 897. 2 "Pathologie," III. 316.

3 Merkel's "Report on Asthma," Schmidt's " Jahrb.," Tol. cix. p. 229.

4 ''Dublin Q J. of Med Sc," May, 1861.
6 "Med. T. and Gaz.," May 16, 1863.

240 RESPIRATORY NEUROSES.

that the air gradually accumulates in the lungs being locked up as it
were by the bronchial constriction. Salter, who has most ably stu-
died the whole subject of asthma, adopts the theory of bronchial spasm
of nervous origin, and states that the chest distension is dependent
on the demand for air, and is observed in all states of insufficient
aeration of the blood. The circumstance that during the worst of
an attack the expectoration is scanty or nil is tolerably good proof
that the small arteries of the bronchial mucous membrane are con-
stricted during this time, and adds to the probability that the bron-
chial tubes themselves are in the same state. It must be admitted
I think as pretty certain that hyperaesthesia of the sensory filaments
of the vagi cannot be the essential pathological state, for this as we
have lately seen induces, not spasm of the minute bronchi and ex-
aggerated action of the inspiratory muscles, but violent action of
the expiratory in cough, with more or less copious expectoration.
The shifting of the dry rales heard during the paroxysm from one
part of the chest to another affords some evidence that the smaller
tubes are at intervals narrowed so as to produce such sounds and
again relaxed. The depression, the chilliness of the skin, the small-
ness of the pulse, the aqueous quality of the urine, remind one some-
what of the cold stage of ague' in which, by the way, along with
various spasmodic phenomena there is " distressed and anxious breath-
ing." If the inspiratory muscles were primarily affected so as to
keep the chest in a state of almost permanent inspiration, there is
little doubt that the will would be able to interrupt occasionally this
morbid action, and to procure every now and then a forced expira-
tion, so that the used-up air might be expelled from the lungs.
This however there seems no power to do. From these and other
considerations, I am led to regard true asthma as a tetanoid disorder
of the motor nerves of the bronchi, and as in great measure depend-
ent like epilepsy on morbid excitability of certain nervous centres,
which are probably located in the spinal rather than in the ence-
phalic districts ; this I conclude from the absence of any tendency
to general convulsions in the asthmatic paroxysm. No doubt there
are many cases where the peculiar excitability would remain inope-
rative except for some peripheral irritation, just as in epilepsy ; and
there may be great varieties in respect of the relative importance
of the central and peripheral causes ; the former, however, I hold to
be the more essential and constant element of the malady. The
necessity of a peculiar predisposition is fully as apparent in asthma
as in epilepsy. The nature of this predisposition may vary very
much, it may consist in a tendency to skin eruption, to gout, or rheu-
matism, or hagmorrhoids, or periodic hemicrania, or uric acid deposits.
All these as Trousseau states are affections which asthma may re-

' Thery says, "Agues run parallel with, or alternate with, asthma . . . . .
the primary cause may determine both disorders." — Schmidt's " Jahrb.," vol. cix. p.
237.

ASTHMA. 241

place, and which in turn may replace asthma. This diathetic ten-
dency which so often leads to asthma is frequently derived from
hereditary descent. The extraordinary capriciousness of asthma is
notorious, and is certainly a matter of high interest and significance.
It proves how wonderfully slight and subtle may be the influences
■which act with great effect on certain states of the nervous system.
Were it not well ascertained how very slight a change in locality
will make all the difference to an asthmatic, we should feel much
disposed to consider the notion as the result of a morbid imagina-
tion. This should be remembered by us in dealing with other and
still more obscure neuroses. The influence of the withdrawal of
light on asthmatics is remarkable. One of my hospital patients, a
male, £et. 35, declared that "when it gets dark he is done alto-
gether," and another, a female, set. 75, found her paroxysm come
on at nightfall, whether this occurred early, as in the winter, or
late, as in the summer. Trousseau^ mentions the case of an asth-
matic who when his attacks came on had five or six moderator
lamps lit in his room, and was immediately relieved. Though the
neurotic character of asthma is, as these and many other facts show,
extremely marked, yet it is clear that it difi"ers from many of the
more common, and especially the sensory neuroses, in that it is not
associated at least frequently or intimately with marked signs of
nerve debility. On the contrary, as Mr. Pridham observes, asth-
matics are for the most part gifted with extraordinary energy and
talents. The admirable Trousseau, who acknowledges his infirmity
in this respect, is an instance in point.

The treatment of asthma is eminently that of a neurosis. It con-
sists first in the removal of all causes of irritation, such as catarrhal
inflammation of the bronchi, dyspeptic disorder, unwholesome diet,
and unsuitable climate, &c., and secondly in the use of various appro-
priate tonics and sedatives. The prophylactic management of asthma
involves as one of its most important parts the selection of a suitable
locality for the invalid's residence. This can scarcely be determined
except by trial. It should be borne in mind that the air of large
towns is in not a few cases more beneficial to an asthmatic than
that of the country, and that where there is a tendency to asthenic
bronchitis a relaxing climate is unsuitable. Though the averting
of pulmonary catarrh is highly desirable, we must remind our patients
that no amount of guarding against cold will protect them against
the stroke of influenza, which by the way seems to me to be far the
most frequent cause of catarrh ; and also that the best way of effect-
ually resisting the morbific action of cold is to tone and fortify the
system so that it may be well able to endure it. It is truly a re-
markable thing how the same temperature that withers and destroys
the feeble vitality of the two extremes of age, invigorates and in-
creases the life of the strong and healthy. An old lady, however,

' "Clinique Med.," vol. i. p. 539.

16

242 RESPIRATORY NEUROSES.

under my care told me once that she was "quite well and wound
up" as long as a sharp frost continued in December; as soon as the
thaw set in she got a cold, tracheal cough and expectoration. On
the frost setting in again sharply she rallied and became more vig-
orous. It was remarkable this year, 1864, how very general catarrhs
became as soon as the frost ceased. Cold bathing or sponging, reg-
ular outdoor exercise, a suflficient but not excessive amount of cloth-
ing, avoidance of damp, chilling draughts when sitting still, are the
main points to be observed by the invalid who is fearful of taking
cold. Of course, in every case judicious adaptation of general rules
to the individual condition is essential. The importance of a duly
regulated diet is well known, and has lately been especially illus-
trated by Mr. Pridham.^ He restricts his patients at first to two
ounces of fresh meat with as much dry bread for dinner at one P. M.,
and the same for supper at seven, allows a cup of tea with cream
and dry bread in the morning, and for drink weak brandy or whiskey
and water, which is not to be taken till three hours after animal
food. Rest is also enjoined for the same period, though air and ex-
ercise are recommended. Three grains of extr. conii are given four
times a day, just one hour before each meal. As the symptoms im-
prove the diet is increased, though it is still very spare and simple.
The rationale of this proceeding is very evident; it is manifestly
well adapted for patients who betray any symptoms of disordered
digestion or assimilation. As there seems no doubt that the ma-
teries morbi of gout may give rise to asthma, so it is very possible
that unhealthy products of digestion may act in a like manner. In
most of Pridham's cases the urine was habitually loaded with lithates,
indicating an excess of acid passing oflF by the kidneys. The more
our pathological knowledge increases, the more do we find that many
different causes are capable of producing the same effects. Prid-
ham professes to treat in the above way only what he terms dys-
peptic asthma, though he seems inclined to extend the significance
of the term rather widely, as he says that he is convinced that an
asthmatic person can never with impunity eat and drink as other
people do. An inveterate asthmatic who was once under my care
told me, however, that, though he was obliged to be careful in his
diet, yet he could go out to a dinner party and eat and drink like
any one else and not be the worse for it. He also found, as indeed
occurred while I had him in view, that when he got bronchitis the
asthmatic attack ceased. Trousseau gives an exactly similar case.
Such instances show clearly the essential difference between inflam-
matory catarrh and asthma. Gymnastic exercises, riding, sawing,
bowling, have been praised for their good effects ; and, as tending to
diminish excitability and increase tone and strength, they are likely
to be useful. Compressed air has recently been introduced as an

' "Brit. Med. J.," June 9th, July 28th, Sept. 1st, 29th, Nov. 17th, Dec. 29th,
1860.

ASTHMA. 243

agent in the treatment of various pulmonary affections, including
asthma. Sandahl in his paper* states that of fourteen cases of asth-
ma and pure simple pulmonary emphysema all were improved, and
twelve as far as could be made out had experienced no relapse. Of
seventy-seven who suffered with asthma, emphysema, and chronic
bronchitis, fifty- seven were improved and twenty either doubtfully
or not at all. From Vivenot's observations'^ it appears that the
effects on the system are slowing of the pulse and the respiration,
diminution of the pulmonary and cutaneous exhalation, increase of
the urinary secretion, and prevention of congestion in the parts on
which the air acts. It may reasonably be expected that benefit
would result from these baths in all cases of catarrhal affection of
the air-passages, but in pure spasmodic asthma it is not very apparent
how they could act beneficially, nor does there seem sufficient evi-
dence to prove that they have done so. M. Beau^ finds sulphuret
of potassium baths not only to relieve the attacks of asthma, but to
prevent their recurrence. Each bath should last twenty minutes,
and thirty should be taken, one every other day. The temperature
should be 86° F. Certain tonics seem to be of real use in not a few
cases. I have found arsenic sometimes of much advantage, admin-
istered in doses of "i^iv — v of Fowler's solution ter die. It may
be given with ammonia and tr. camph. co., or alone, or with an or-
dinary cough mixture, according to circumstances. We should assure
ourselves before giving it that it is likely to be tolerated by the
stomach. When there are indications of gastric as well as of bron-
chial catarrh, nitric or muriatic acid is preferable in combination
with acid, hydrocy. dil. and tr. calumb. When there is bronchial
catarrh alone, atropia with or without nitric acid is a valuable remedy.
I have had a case recently under my care which has terminated very
satisfactorily under atropia gr. yi^ ter die, and tannin with Canada
balsam in pills. Atropia is a remedy on which I feel much inclined
to rely both from experience of its power as a sedative, and from the
observations of Dr. Williams as to its abolishing the contractility of
the bronchi, which is just what is desirable in asthma. Cannabis
indica has occasionally proved very useful, gr. | doses of the extract
immediately checking the spasm. In one case where asthma super-
vened upon phthisis great relief was afforded by the subcutaneous
injection of liq. opii sed. ^L x into the left front of the chest.
M. Courty^ has also obtained very good results from subcutaneous
injection of atropine (gr. -^ thrice repeated) in the vicinity of the
left vagus nerve. Dry cupping should be persistently employed as
long as there are signs of congestion of the bronchial mucous mem-
brane. In some cases pot. iod. proves very beneficial. With regard
to the shorter and severe paroxysms I can do little more than

' Schmidt's "Jahrb ," vol. cxx. p. 178.
2 Ibid., vol. cix. p. 33-5.

* "J. de Med. et de Chir. Pratiq.," vol. xxxiii. p. 440.

* "Gaz. Med.," Nov. 1859.

244 RESPIRATORY NEUROSES.

enumerate the various remedies which have been found efficient. Ice
pills according to Romberg often afford instant relief, and inhalation
of sulphuric ether or chloroform may be very serviceable. Smoking
tobacco, or stramonium, or a compound of the latter with belladonna,
will sometimes quell the spasm. Ipecacuan emetics may be given
for the same purpose. Opium combined with spt. £eth. s. co. has in
some cases a good effect. Nitre paper should not be forgotten,
made according to Dr, H. Salter's formula by soaking red blotting
paper in a solution of giv of pot. nitras in aq. Oss. In some in-
stances Ducros' medication or a modification of it is beneficial. He
brushes the posterior wall of the pharynx with a strong solution of
ammonia, liq. ammon. + aq. aa 5J. The first time that Trousseau
tried it he thought the patient would have died suffocated. He
states, however, that " employe dans une juste mesure il a rendu de
reels services." Probably M. Faure's plan is preferable. He puts
Sss of liquid ammonia in a bowl, and desires the patient to inhale
the vapour, taking care, however, to close the nostrils. The inhalation
is to be continued for fifteen minutes, and to be repeated four times
a day. Trousseau relates that the captain of a ship was always
exempt from the paroxysms while his vessel was loaded with guano,
or he was staying at the gathering grounds. Various stimulants are
occasionally beneficial, strong coffee, tea, ammonia, and alcohol.
Dr. Salter^ has recently published some remarkable evidence of the
power of very large quantities of the latter to subdue paroxysms of
the disease which had proved refractory to all other measures. In-
toxication was not necessarily produced. The efficacy of alcoholic
and other stimulants I believe to depend on the circumstance that
their action on the nerves or nervous centres replaces advantageously
the morbid action which previously affected them. We have here
another instance of the affinity between spasm and paralysis, both
being advantageously treated by the same means.

To prevent recurrences. Trousseau advises a compound medication
consisting of ten days of small doses of belladonna, as many of tur-
pentine, and the remaining ten of the month of arsenical cigarettes,
besides a sixty grain dose of powdered calisaya bark in coffee every
ten days. This plan must be followed out a long time and very
exactly.

Sneezing and hiccup are two minimum disorders as they usually
occur, but they occasionally develop themselves to the dignity of a
disease. Romberg cites several instances of the former occurring
either in his own experience or in that of others. It is met with
occasionally as an accompaniment of hooping-cough, and of ver-
minous disorder, as well as in the so-called hysterical state. Mosler
relates a case,^ in which a scrofulous female was computed to have
sneezed 50,000 times in eighty hours, and the neighbourhood was
alarmed ! She was amenorrhoeal, and the disorder returned a month

» "Lancet," Nov. 14, 1863. ^ .<Med. T. and Gaz.," June 25, 1859.

SNEEZING. 245

after Its first attack. The only instance I have met with was in the
person of a mid-aged gentleman, who had suffered from dysentery in
India, and had quite recovered, but no doubt still retained some-
thing of the malarious influence, which gave rise to the nasal flux.
Romberg describes ordinary sneezing as a reflex act excited by irri-
tation of the nasal filaments of the fifth pair, as well as by other
filaments of the same nerve, and of other and remote nerves, such as
the intestinal and uterine. This is no doubt true in many instances,
but it seems to me also pretty certain that the morbid action is very
often central rather than peripheral in its seat. In fact where no
cause of peripheral irritation can be discovered it seems most reason-
able to suppose that the seat of disease is in the part where most
vital action and change is going on. At any rate the possibility of
this cannot be denied. The circumstance which I have often ob-
served that a hot room will cause sneezing which subsides when the
air is cooled is in favour of this view. The heat relaxes the general
tone, but could not irritate peripheral nerves. One circumstance
which appears very noteworthy in sneezing is the muco-watery se-
cretion, which is sometimes very considerable. In one of Brodie's
cases the watery fluid dropping from the nostrils was sufficient to
wet a handkerchief completely through. Now it is certain that the
exudation is not the mere result of the air-blast passing through the
nasal cavities; it seems to be, as well as the morbid sensation which
determines the expiratory act, the result of deranged innervation.
We can scarcely err in regarding the vaso- motor nerves as implicated
in this occurrence, and that necessarily in the way of paralysis.
How this comes to pass is not so clear by any means. Of course,
when an irritant, as snuff, is directly applied to the mucous surface
we may consider that the tissue and the nerves are both directly
affected, but this will not serve for the cases where no local irritant is
applied, or where the local irritation is remote. I see no way of
rendering a rationale of this common occurrence, except by refer-
ring it to the theory of inhibitory action. The muco-watery pro-
fluvium is the result of reflex inhibitory irritation, congesting the
vessels and promoting exudation. If indeed the profluvium were
derived from any large gland the reflected irritation might be sup-
posed to affect this in the ordinary way, but as in all probability it
is poured out from the general mucous surface this explanation will
hardly apply. Another mode in which we can conceive the phe-
nomena to be linked together is that some central change gives rise
at one and the same time to the pain and the paralysis, each being
expressive of disorder of a similar kind in a particular kind of nerve.
Romberg's case of facial neuralgia gives support to this view [v. p. 37,
*'Syd. Soc. Transl.")

When there is no discoverable cause for the paroxysms the usual
anti-neuralgic treatment is generally indicated. One of Romberg's
cases was cured by carbonate of iron, and my own was very much
benefited by iron and quinine with Fowler's solution.

246 RESPIRATORY NEUROSES.

Hiccup is described by Copland as consisting of a sudden and
' rapid contraction of the respiratory muscles, of the diaphragm es-
pecially. Romberg thinks this erroneous, and does not allow that
irritation of the phrenic nerve is concerned in producing it. He
bases this opinion on two cases recorded by Bright in which organic
disease affecting the right phrenic nerve produced other nervous dis-
order, but no hiccup. He ascribes its occurrence to reflex irritation
having its starting-point in the alimentary canal, the liver, or the
uterus, but admits also that its cause not unfrequently resides in
the central nervous organs. Copland states that it is often produced
by locomotive biliary and renal calculi, as well as by strangulation
of internal parts, and external injuries, and fractures of the ribs.
It is not an uncommon and distressing symptom towards the fatal
close of acute diseases and fevers, especially in advanced life. The
form of hiccup which most concerns us here is that which constitutes
per se the whole or chief disorder and is not merely symptomatic.
This seems for the most part referable either to obscure nervous
disorder such as is loosely called hysterical, or to malarious infection.
Of the latter a good instance is recorded by Widal (Cfaz. Med. de
V Algerie). The patient was admitted at first suffering under the
consequences of cerebral congestion. Five or six days after having
committed excess in drinking he was seized with violent hiccough,
the incessant spasms of which compelled him to remain in bed, and
resisted all treatment by anti-spasmodics. The hiccough was so in-
tense and noisy that it was heard outside the hospital. The number
of diaphragmatic contractions reached 55 in the minute, and their
energy was so great that all the muscles of the trunk participated
in them. There was considerable dyspnoea, short inspirations, red
face, white tongue, loathing of all kinds of food, pulse small, 80.
Opii gr. \ was given every two hours, and a blister to the epigas-
trium was dressed with morphia, but no improvement ensued. The
patient had no sleep, and his strength was failing. At last quinine
in pretty full doses was given, which speedily put an end to the dis-
order, after it had lasted nineteen days. In all cases where the
patient has ever been exposed to malaria we should consider whether
this may not be the cause of the disorder. It is rather remarkable
in the foregoing case that the neurosis was continuous, not periodic.
Romberg mentions a case occasioned by violent fright, in which the
hiccup was complicated with, and alternated with attacks of spasm
of the glottis. The patient was a female, set. 21, with regular
catamenia. I see no reason for denominating such a case hys-
terical any more than one of chorea, produced as it often is in the
same way. The seat of the disorder in both the above instances,
and indeed in most, I believe to be central, though it is difficult to
say precisely what nervous centre is affected. Probably, however, it
is the upper part of the cord about the origin of the fourth cervical
nerve. The causes which give rise to hiccup are most often of a
debilitating kind, and there can be no question that the condition

HICCUP. 247

of the nervous centre is rather one of exhaustion than of increased
energy. The affection may be viewed as a kind of local chorea,
and like it is the result of abnormal excitability aud weakness in the
nervous tissue.

Very various treatment has succeeded in cases of non-malarious
hiccough. In individuals exhausted by profuse discharges a full
dose of opium is praised by Sydenham. In an opposite condition,
viz., suppressed menstruation, Berends obtained a cure by taking
three ounces of blood from the foot. Blisters to the neck are some-
times useful. Mental influences occasionally are potent remedies.
Cruveilhier seems to have cured two bad cases by half drowning
them with water poured down their throats. Swallowing lumps of
ice I think would prove often an effectual remedy. Laennec was
successful with milder measures in the form of magnetic(?) plates
applied to the epigastrium and opposite region of the spine. Elec-
tricity, as it has proved beneficial in chorea, might be so also in this
allied disorder. In some cases the interrupted, in others the con-
tinuous current might be suitable. The former should be used in
cases where there was evident asthenia, the latter in those where
there were indications of sthenic excitement. Various stimulant
and tonic medicines might be administered internally according to
the condition of the patient. One of the best is assafoetidas gr. x in
pil. ij, 2dis Jioris sd. The practitioner will do wisely in cases where
the neurosis is idiopathic and obstinate to mingle with his treatment
as much of the " medicina mentis" as possible. Nothing is more
certain than that even actual bodily disorder is very materially in-
fluenced by mental affections, and this is eminently true of the
neuroses.

Yawning is a small neurosis, which however has some points of
interest for the thoughtful practitioner. Thus, though clearly a
muscular action, it must be ascribed to diminution of nervous energy,
and is thus a similar pathological instance to chorea and hiccough.
Then it is unquestionably a communicative neurosis, and though of
course we must take into account the circumstance that a number
of individuals who are together are likely to be in the same state of
fatigue, &c., yet it is certainly remarkable that witnessing this small
spasm in a companion should cause others to imitate it involuntarily.
One's thoughts of course recur to the communication of epilepsy in
the same way, and one cannot but observe how in smaller as well as
in greater matters our organism is swayed by the same rules. As
these are communicated other neuroses may be so too, a circumstance
which should make us not indifferent to the protection of the young
and impressionable from sights which might affect them injuriously.
Mothers firmly believe that squints are catching, and I am not sure
that they are not right. At any rate it is best to err on the side of
safety. Romberg assigns to the uterus a large share in the pro-
duction of yawning, and affirms consistently that it is much more
frequent in the female than in the male sex. This I take leave to

248 MYALGIA.

doubt, and am much more inclined to acquiesce in his admission
that it may be of central origin, as is seen in apoplectic attacks.
To my mind it, is commonly of centric origin, at least when it results
from fatigue, and betokens a state of temporary nervous exhaustion.
It is worth observing that it is a common occurrence at the com-
mencement of the cold stage of an ague.

CHAPTER XXIX.

MYALGIA.

In this disorder it appears to me that the sensory nerves of the
muscles must be essentially implicated, as if they were not it is im-
possible to conceive how the pain which gives its name to the
affection should be experienced. The muscles, it is plain, are wpak
and readily exhausted, their functional power is low. But if this
were all, the phenomena would be simply those of paresis or im-
perfect paralysis, and there would be no pain. The pain is like
that of ordinary neuralgia in being calmed by repose, reproduced
by exertion, and removed by nerve tonics. I therefore regard
myalgia as a muscular neuralgia, and believe that it is to be treated
exactly on the same principles as neuralgia in any other situation.
The weak and aching muscles are to be rested sufiSciently, but not
left on the other hand without adequate exercise. The general
strength and vigour must be promoted as much as possible by diet,
air, and medicines. The following case is a well-marked instance.

No. 117. — S. B., m., get. 25. Ill three months. Pallid, of small make,
ordinary temperament. Functions in fairly good order. Complains of
pain at top and back of right shoulder which ceases if he leaves off work
for a few days, but returns again on resuming it. The seat of the pain is
in the supra-spinal fossa. When passing his stitches in boot-making he
feels as if the shoulder were pulled out of its place. Has been ordered warm
baths without benefit. Under steady perseverance in the administration of
quinine with iron, or strychnia, and ol. morrh., he recovered completely in
about three months. During the last six weeks he was able to follow his
employment. It is very easy to confound this disorder with chronic rheu-
matism; from which it is chiefly to be distinguished by its complete sub-
sidence during repose and aggravation by exertion. The profession is much
indebted to Dr. Inman, of Liverpool, for having first accurately described and
distinguished it.

ABDOMINAL NEURALGIA. 249

CHAPTER XXX.

ABDOMINAL NEURALGIA.

Under this head I propose to consider various more or less pain-
ful aflfections, which appear to have their seat either in the viscera,
or in the parietes of this cavity. They are often difficult of manage-
ment, and their existence is as yet far from being generally known
to the profession. What I know respecting them I have learned
almost entirely from experience, and I believe I shall do best by
relating various cases which have occurred to me, and subjoining
some comments upon them. In the first group of instances I shall
give, pain is the chief or only symptom, the sensory nerves seem to
be alone affected.

No. 118. — J. B., m., set. 14, pupil- teacher, intellectual-looking and
delicate, worked rather hard in a school. Ad. January 28th. Ill three
days. Has pain in abdomen causing him to bend double at times, some
cough and pain in chest; food causes no pain. Much headache at times.
Forehead cool. Abdomen somewhat tender to pressure ; the pain in it
ceases when he is recumbent. I urged his being removed from school, as
the confinement was evidently injurious, but this was not done. Citrate of
quinine and iron with a little pot. iod. and chloric aether was given for
fourteen days without advantage. Subsequently he took a combination of
ammon. carb., ferri ammon. citr., tr. nucis vom. and infus. calumb., with
which he benefited immediately, and was discharged well by the end of
April.

No. 119. — J. N., m., get. 13, ad. June 4th, ill two days. Was attacked
while at work with pain in abdomen and violent sickness and purging.
These have ceased, but the pain continues, and there is considerable tender-
ness on pressure over the umbilical region, but not elsewhere. P. small,
100. T. slightly furred. Pupils of medium size. Has had a dose of ol.
ricini. Although I have had an eye to detect abdominal neuralgia for some
length of time, I doubted seriously in this case what was the exact state of
matters. The boy had walked to the hospital, and his aspect was scarcely
that of a person affected with peritonitis. Yet the tenderness was so marked,
and there was such an absence of hysterical exaggeration, that I was fearful
of treating the disorder as mere neuralgia. So I gave him then and there
tr. opii Tr^xxx in an enema, and after he had lain still awhile and seemed
freer from pain I ordered him pil. saponis co. gr. v, otiis vel iiis horis. 8th.
Apyretic, has still much abdominal pain, but some appetite. The course was
now clear; I gave him ferri et quinae citratis gr. vij ter die, and in fourteen
days he was almost well, ailing only with great debility.

No. 120.— Gr. E., set. 13, m., ad. Nov. 21st, ill three months. Has fre-
quently violent pain in his bowels, "and is all drawed into a lump."
Flinches Very much from pressure on abdomen. When lying down the recti

250 ABDOMINAL NEUEALGIA.

muscles are very tense, but when his attention is distracted he lets me
manipulate his abdomen without much complaint. Has "cold shivers"
when the pains are present. B. open, has pain when they act. Has taken
his food pretty well till last two days. Very languid and drowsy. Has
been under medical care and been salivated for supposed inflammation of
bowels. I gave him at first citrate of iron and quinine, ter die, and lin.
opii; from this in a week he was little if at all better; it was then changed
for muriate of ammonia, gr. x ter die, but without any advantage ; the
paroxysms of pain lasted from ten to sixty minutes. He then had ferri
carb. saccharati gr. xv vel xx ter die. This was of material service, but
still the enemy was not quelled, the pain reappearing two or three times a
day. A bismuth mixture with hydrocyanic acid given along with the iron
only caused sickness, and I was beginning to get disheartened, and to sus-
pect malingering, when at last I prescribed pot. iodid. gr. jss ter die, con-
tinuing the iron, and in a fortnight he was quite well.

No. 121. — H. H., m., set. 13, ad. March 19th. Has been laid up two
months. Looks very healthy. T. clean. B open. Has pain in abdomen
commencing in the region of the caecum and following pretty regularly the
course of the transverse and descending colon. He describes the pain as
"wretched agony," lasting five to fifteen minutes. His father thought he
would have died some days ago. Exertion brings on the pain ; is not
attacked nearly so much at night when lying still. Has been blistered without
benefit. Skin cool. P. weak. Citrate of iron and quinine and spt. seth. s.
CO. did good, but was not nearly so efficient as muriate of ammonia with
bark, on which he improved so much that he was nearly well when he
ceased attendance a mouth later.

No. 122.— J. G., f., set. 23, ad. March 26th. Ill three days with severe
pain all over lower part of abdomen and extending to back, not relieved in
bed. Pain increased when bowels act. Abdomen not swollen. Catamenia
just ceased, lasted only two days. Not anaemic. T. clean, moist. The
pain was very much like that of limited peritonitis, but not so much in-
fluenced by pressure. I injected liq. opii sed. rtix into the hypogastrium
subcutaneously, ordered an opiate liniment, and pil. saponis co. gr. v,
ter die. 30th. Was very much relieved by the injection, "it seemed to
expand her stomach and remove the pain." Catamenia returned and con-
tinued three days, B. confined. Urine much paler. P. very feeble.
With ferri and quin. citr. + chloric aether she improved materially and
soon ceased attendance.

In the case of a young female ^t. 15, whose catamenia were reg-.
ular, and who showed no traits of hysterical character, there was a
history of numerous fits of epileptic nature, which continued to
recur at longer intervals. In one, which I witnessed, both the legs
and the left arm were rigid, the right was mobile, and there ap-
peared to be complete unconsciousness. She had very severe ab-
dominal neuralgia, which was temporarily quieted by opium and
decidedly checked by full doses of quinine. She went on very well
for some time afterwards with citrate of iron and quinine and ol.
morrh., but afterwards had some relapse. Country air had been of
great advantage to her health previously, but she drooped as soon as
she returned to London.

ABDOMINAL NEUKALGIA. 251

Remarks. — It may be observed that the subjects of most of
the above cases were boys, who probably have less tendency to hypo-
chondriacal exaggeration than most persons. Nevertheless I must
confess that on one or two occasions I was much inclined to suspect
the patient's honesty until the speedy success of a particular remedy
proved that it was my skill that was defective, and not his "morale."
In none of the cases related did the neuralgia appear to be referable
to lead ; the gums showed no trace of blue line (my notes mention
this specially in three). One very practical point which the above
histories illustrate is the different quality of the morbid action in
different cases which appear very much alike, and the great difficulty
there may be in selecting the right remedy in any given instance.
"Where pot. iod. succeeds, we may regard the aponeuroses as most
affected ; where muriate of ammonia avails, the muscular fibres ; and
where iron and quinine carry the day, we may consider that the
neuralgia is more of a simple than rheumatic character. This
knowledge after the event does not avail us however before it, and
I believe it will often be necessary to have recourse to trial, which
however need not generally be prolonged. It would be easy to in-
dicate points, as the state of the urine, the previous history, the
effect of moving about, which might serve as aids in diagnosis, but
I believe they are unreliable. Increase of pain, for instance, on
moving, which would be a sign of muscular rheumatism, might easily
be present in fibrous. Pale and low sp. gr. urine would certainly
indicate most probably simple neuralgia, but lateritious urine would
be no certain sign of rheumatic disorder. As to the exact locality
of this neuralgia, it seems to me that we may agree with Romberg
in referring it to the superior mesenteric plexus and its ramifications.
From the neuroses which are so definitely referred to the epigastrium,
and which probably have their seat in the solar plexus, it is cer-
tainly distinct. In the case where subcutaneous injection acted so
efficiently it may be thought that the disorder was seated in the an-
terior parietes of the abdomen, but I doubt whether this is suflScient
ground for the opinion, as in another instance a severe and well-
marked gastralgia was relieved equally well by the same means.
The relation of this disorder to common neuralgia in other situations
is marked by its being associated almost invariably with general
debility, by its being cured by the same remedies, and by its occur-
ing occasionally as a result of malarioid fever in children.

That the afi"ection now described is not well known in the pro-
fession seems pretty clear from the history of a case recorded in the
Brit. Med. Journ. by Dr. Martin, of Rochester, July 16th, 1859. A
boy, set. 10, tall and active, sufi'ered with attacks of pain in the
bowels, which had become gradually longer and more severe. The
abdomen felt soft and bore pressure well when pain was absent, but
the least touch was intolerable, and all the surface of the body was
preternaturally sensitive, when the pain was present. When the
attack began to come on he appeared frightened, and threw himself

252 ABDOMINAL NEURALaiA.

on the ground writhing to and fro in great agony; the pulse became
very rapid, and the face covered with profuse perspiration. The
pain seemed to begin in the coeliac plexus of nerves, and to shoot
into all the abdominal viscera, and to the region of the heart. A
London physician who was consulted thought that the disorder
might depend upon lead-poisoning, and prescribed alum and change
of air. These and much other treatment failed, until at last ferri
carb. was given, which cured the disease.

The neuroses which occupy the upper abdominal region, and
commonly involve the stomach, may be reasonably supposed to
affect, at least in many instances, the solar plexus. Romberg de-
scribes a cceliac neuralgia or hypersesthesia of the solar plexus, the
pathognomonic feature of which is a peculiar sense of fainting and
annihilation accompanying the pain. The treatment of this he says
does not differ in any essential point from that of gastrodynia. I
find great difficulty in making any arrangement of the very various
and interesting cases of nerve disorder which affects this region.
Some rough discrimination may be made of instances in which some
hyper- or dyssesthesia predominates, of those in which motor dis-
order (vomiting) is the prominent feature, and of those in which the
rejection of various morbid products is a chief phenomenon. In
some cases it appears that the terminal ramifications are more
affected, in others the disorder appears to be more central.

No. 123.— K. T., f, get 9, ad. Feb. 15th. Ill five weeks, pale. Com-
plains that she has pain after eating, and at other times. It is severe at
night. No marked epigastric tenderness. No appetite. All her food lies
heavy at her chest, but she never vomits. Has constant thirst. P. feeble.
T. clean. Skin cool. With citrate of iron and quinine and ol. morrh. she
recovered speedily.

No. 124.— M. A. T., f., set. 60, ad. Oct. 29th. Short and stout, of rather
sanguine aspect. Ill two or three years. Suffers with pain commencing
under right ribs which passes to middle of abdomen and epigastrium, and
backwards to the interscapular space j "a dreadful burning pain it is," and
attended with much flatulence and nausea. It lasts five or six hours, and
goes off leaving much soreness and depression, " so that she does not know
what to do." Food does not affect it at all. The pain used to come on
for six weeks every day while she was at Swindon; after coming up to London
she was free for fourteen days. She has been dosed with emetics, which made
her bring up much blood (Oss. at once) mingled with phlegm, and has taken
opiates which made her sick. T. white. Urine generally pale and copious.
Appetite good, except when pain is on her. B. regular. P. good. No
fever. Never had ague. With quinine, iron pot. iod., ammon. carb. and
bark she improved very much, so that on Dec. 5th she reported that she was
getting quite well except some pain about the head. It seemed, she said,
like new life to be relieved from the stomach pain. This patient had had
rheumatism severely two years before, and her gastralgia probably contained
a rheumatic element.

No. 125. — J. S., set. 2, m., ad. Aug. 27th. Since he had measles seven
or eight months ago has suffered much with pain at lower sternal region,
"is always beating it day and night." Has had pertussis recently. Lips

ABDOMINAL NEURALGIA. 253

swelled, cracked and ulcerating. With citrate of iron and quinine and ol.
morrh. he benefited greatly.

Remarks. — In the three preceding cases it is clear that the pain was not
a mere gastric disorder, as it was independent of taking food; it was essen-
tially a similar affection to the mesenteric neuralgias which we have just
noticed. In the first case there was constant thirst, a very misleading
symptom, and which one may certainly affirm would not have been quieted
by salines. It is a less common dysaesthesia than pain, but was present
(periodic) in the case recorded by Brodie.^ In the second case the burning
pain and the sanguineous vomiting might have raised suspicions of ulcer.
Gastralgia is rare in such young subjects as that of the third case.

No. 126. — S. H., f., set. 39, ad. Jan. 7th. Ill fourteen days. Suffers
with pain in the stomach, chest, and back, which is as bad in the intervals
of her meals as directly after. No pain on pressure. One article of food
has the same effect as another. Is quite free from pain when lying down.
Drinking warm water gives great relief to pain. Has been worked hard.
Appetite tolerably good. T. clean. B. costive. With ferri sulph. gr. iij.
+ pulv. cinnamomi co. gr. v + aloes gr. j in pil. ij ter die she quite re-
covered in about seven weeks. Citrate of iron and quinine was tried for a
short time, but was less efficient than the first combination.

No. 127. — A. F., set. 43, f., ad. June oOth. Ill two years with pain in
abdomen, at lower chest, and between shouldei's, much worse after eating;
one kind of food causes as much pain as another. Wine or beer disagrees,
and even gruel brings on the pain. Never vomits, but has nausea, and
watery fluid rises up into her mouth. No appetite. Not thirsty. Urine
very high colored, clear, scanty. Argenti nitras with extr. hyoscy., bis-'
muth with tr. opii were of little avail, and strychnia was injurious, but ferri
carb. 5j ter die, with lactic acid at meals continued for about eight weeks
effected a cure.

Remarks. — The two last cases form a kind of transition to those where
the disorder has more the character of hypersesthesia than pain. The com-
bination used in the first is nearly the same as that employed by Aber-
crombie {v. Dis. of Stomach, p. .51) with success in a very intractable case
of gastralgia. The lactic acid was very beneficial in the second case. I have
used it now for several years, and am quite satisfied of its value as a peptic
when the functional power of the stomach is low, and its nerves are weak
and irritable. In certain cases it is I think decidedly preferable to muriatic
acid. That which I have used has been prepared for me by Mr. Blades, 52
Edgeware-road, a most careful pharmaceutist.

The following history is worth recording from the distinct con-
nection which it exhibits between a respiratory and an abdominal
neurosis.

No. 128. — Mrs. , set. 43, seen April 9th. Has been suffering for

some weeks with bronchial catarrh, and latterly also with pain of a weary-
ing aching kind at the epigastrium, and along the margin of the ribs. She
has been getting weakly and nervous for some months. I prescribed citrate
of iron and quinine + chloric ether + tr- nucis vomic, and the pain soon
disappeared, but one night a violent attack of asthma came on, so severe
that she seemed to be in danger of actual suffocation, and at the same time

1 Local Nervous Affections, p. 80.

254 ABDOMINAL NEURALGIA.

bronchitis was set up; she had cough, expectoration, and wheezing, with dry
large tube rales in both lungs. Under the use of ipecacuan, morphia, &c.,
this subsided, but she became extremely weak, and had again pain in the
former situation, and also in both loins. She again took iron and quinine,
and the pain diminished much, but on account of some nocturnal febricitation
I changed this for quinine gr. ij ter die. In a day or two after she had a
most severe attack of the pain in the abdomen attended with retching. It
occurred at night, entirely prevented sleep, and was relieved at last by a glass
of brandy about 4 A. M. The next day she was free from severe pain, but
exceedingly sore and tender all about the epigastrium, right hypochondrium
and loins. There was decided tenderness, and the discomfort and dysaes-
thesia were much aggravated by turning to the left side. The urine was
clear, acid, not red. The next night she slept well with a "nightcap"
of hot brandy-and-water. She subsequently took carbonate of iron and tr.
cinchonas, and I ceased to attend her. The bronchitis had been attended
with more or less of asthma every morning, for which she had been smoking
stramonium with benefit, but after the severe attack of gastralgia the cough
and chest affection almost disappeared.

No. 129. — J. N., set. 36, m., ad. April 9th. Has been ill since last
August except for about six weeks altogether, and those not occurring con-
tinuously. Is a painter, but has no blue line on gums; had colic six years
ago. Always was a nervous man. Eyes prominent, expression of coun-
tenance hypochondriacal. Lips red. T. coated, dryish. Skin cool. P.
feeble, quiet. Appetite very bad, is thirsty. B. costive. Urine thick, pretty
free. Has continual nausea. Suffers from violent pain at epigastrium pass-
ing right through to shoulder, attended with sickness which comes on after
eating and at other times. The epigastrium is tender, most so towards the
left side. Vomited matters are greenish, mucousy, strongly acid. Food
causes pain as soon as swallowed. Pain relieved by lying on the back. On
15th the urine had an iridescent pellicle on the surface, was neutral, effer-
vesced strongly with acid, and deposited a large amount of white phosphates.
This tendency of the urine to deposit' phosphates continued up to May 12th,
soon after which time he was made an extern patient and came under my
care. He had previously been treated with lime-water, bismuth, prussic
acid, hyposulphite of soda, repeated blisters, leeches, and pepsine, May
17th. His symptoms were less severe, he had had no sickness for six days,
but felt much oppression at the stomach. Argenti nitratis gr. | -f extr.
hyoscy. gr. iv in pil. ter die was ordered. At the end of ten days he was a
great deal better, could take food " quite nicely," felt his chest more free,
and was getting more strength. He then went to the country. Urine was
then pale and clear.

No. 130.— J. W., f., Eet. 22, seen Sept. 6th. Ill seven to eight years.
Suffers with pain and tenderness in left side passing round and extending to
both scapulae, worse after food and exertion. She is often sick and vomits
in a few minutes after food. The vomited matters are very acid. Only
streaks of blood ever brought up. Light food agrees best, but milk is re-
jected. Arrowroot or sago suit. Is easier in morning when stomach is
empty. T. too clean, over-red. Cat. regular. B. open. P. weak. No
fever. Not much flatus. Much emaciated lately. Urine very pale, sp. gr.
1010, not albuminous. She had" been treated six years before for gastric
ulcer. She took argenti nitrat. gr. ^ and opii gr. i in pil. ter die for three
and a half months; in fourteen days she was able to take meat; she gained

ABDOMINAL NEUROSES. 255

two stone in weight and quite recovered. Not a trace of cutaneous dis-
coloration was produced.

No. 131. — Mr. Tw.j aet. 25, seen in consultation with Mr. Cooper. Has
heen ill about four years since a bilious fever in America ; in three months
after this his stomach symptoms set in, and have continued wherever he has
been. He suffers uneasiness at the epigastrium immediately after taking
food, and is not relieved until he has got rid of it, which appears to be
effected partly by vomiting, partly by digestion. The matter vomited is
very acid (tested) and tastes hot and bitter. He vomited about Oj in the
day, by small quantities at a time. It does not appear that he finds much
difference between meat and lighter food ; he suffers even more after beef-tea
than pie-crust. No tumour to be detected in the epigastrium ; the whole ab-
domen is collapsed and soft, the bowels appear empty. Liver descends low
in epigastrium, probably from the loss of any support from below. No no-
table tenderness at epigastrium, but some soreness. At times has much
flatus with his sickness. T. smooth, rather too red. He is very emaciated,
his eyes of a clear white, and his aspect much like that of a phthisical person.
His lungs and heart appear sound. Urine full-coloured, feebly acid. He is
very thirsty, but dares not drink for fear of causing irritation of the stomach.
Has taken bismuth, pepsine, hydrocyanic acid, and strychnine, but with
very little good effect. It was agreed that he should take iced milk in
dessert-spoonfuls every twenty minutes, and nothing else for some days,
except argenti nitrat. gr ^ -}- opii gr. J in pil. ter die. In six weeks he
came to see me at my house, and reported that he was much better, had
gained flesh and strength, had no sickness, and was able to take meat and
other solids pretty freely. The nitrate of silver had been omitted the last
week ; he had had some nausea the last two days. I have not heard of him
since.

Remarks. — The last three cases are good examples of gastric
hyper^esthesia, though I do not assert that this was the sole disease.
The question will occur to most readers whether the symptoms were
not due to ulcer of the stomach. I think it is quite possible that
ulcers may have existed, but I doubt very much whether they were
the cause of the symptoms. In the first case the irritability of the
mucous membrane was such that it led to an excessive pouring out
of acid, in consequence of which the urine was left in a minus con-
dition, and deposited phosphates. I have seen this kind of draining
oflF of acid in a few other instances. In the two other cases the
amount of acid secretion was not so great, but the functional power
of the organ was extremely impaired, and there was great hyper-
sesthesia (local). To diagnose the condition of simple gastric hyper-
sesthesia from that which is associated with ulcer is, except where
perforation of a bloodvessel has occurred, a matter of exceeding
uncertainty. It is notorious that ulcers may go on to perforation
of the whole wall of the stomach without having given rise to any
symptoms at all, and it is quite common to meet with instances
where the symptoms preceding an attack of hsematemesis have been
only those of very moderate dyspepsia. Quite recently I have had
a good proof how distinct the ulcer and the dyspeptic symptoms may
be in relation to treatment. A cook, set. 42, had been under my

256 ABDOMINAL NEUROSES.

care several times with disordered digestion, but of quite an ordinary
character. She had always been pretty speedily relieved by ap-
propriate treatment, and was so on this occasion. She had been
free from pain at the stomach for some time, was discharged on a
Thursday feeling quite well, and continued so until the following
Sunday, when towards night a copious gush of blood, about Oiij, took
place from the stomach, declaring too plainly that her previous
malady had not-consisted solely of the symptoms of which she was
conscious. After long attention to this subject I incline more and
more to the opinion that, except in some particular instances, ulcer-
ation per se produces no distinctive signs until perforation ensues,
and that the pain and functional disorder with which it is often at-
tended are no necessary results of the lesion.' Their existence de-
pends much more on the state of the general mucous surface than on
the presence of ulceration. Of the value of nitrate of silver in con-
ditions of gastric hypersesthesia I have myself not the least doubt,
though I feel how difficult it is to account for its action. I do not rely
at all on the above cases to prove its virtue, because it was given (ex-
cept in the first) along with opium. This is usually a useful adjunct,
but I have certainly seen the nitrate beneficial when given alone, and
I am satisfied that its action is more and other than that of the seda-
tive. Its influence on nervous tissue is attested by the good effects it
produces in "ataxic locomotr. progressive." The difference between
gastrodyhia and gastric hypersesthesia is well illustrated by these
cases.

No. 132. — Gr. C, m., set. 49, ad. April 15th, getting gradually ill two
months. States that whatever he eats or drinks all returns again, either in
a few minutes, or in one or two hours. Food does not cause pain im-
mediately. Epigastrium not notably tender. The vomiting begins with a
pain about the umbilicus, which " works upward" and produces the sickness.
No sign of any tumour. Of placid quiet demeanour. Rather pale. T. nat-
ural. B. regular. Urine copious, has not full control over it. "With strych-
nia and liq. opii sed. ter die, he was quite well in a month.

Remarks. — In this case, and such are not infrequent, motor disorder was
a much more prominent symptom than pain. The aflfection might almost be
called a chorea of the stomach. The chief action of strychnine is on the
nervous motor apparatus, and thus it proves a suitable remedy in conditions
like the above by its toning and steadying influence.

No. 133. — E. H., get. 30, labourer,' ad. Jan. 16th. He had been suffer-
ing eight or nine months with violent pain in head and chest, aggravated
after taking food. He was treated at first with bismuth and hydrocyanic
acid or opium, and a blister, but with only temporary amendment. February
5th. He has still great pain after eating, and vomits all his food in one
hour after taking it. Much tenderness in epigastrium and pain all about
prsecordia. G-reat thirst. Pulse small and feeble. Skin cold. Urine very
clear and pale. A blister was ordered to the epigastrium, and muriatic +

' Dr. Wilkes informs me that Dr. Habershon concludes from his dissections that the
presence or absence of pain depends on whether the ulcer does or does not involve
nervous filaments. I doubt whether this expresses the whole truth.

ABDOMINAi. NEUROSES. 257

hydrocyanic acid ter die. 9tb. Symptoms unchanged. Is shaking with ague
tremor, and states that he does so several times a' day. States that last year
he was under my care with distinct ague of tertian type, the paroxysms
being however rather obscurely developed. He was not thoroughly cured,
having discontinued treatment too soon, and has suflfered in the same way
oflE" and on ever since. He comes from Pinner near Harrow, where ague is
prevalent. The case was now clear. He took quining + iron with benefit,
but ceased attending before he was thoroughly well. After he had had the
tonics for three days, as he was still suffering, though less, I injected liq.
opii sedat. n\^ x subcutaneously into his epigastrium. Four days later he
reported that he had felt very giddy in walking home (ten miles), but
that in about six hours he was relieved of the stomach pain, which had
quite ceased until his dinner yesterday reproduced it to some extent.

Remarks. — The resemblance of this case to ordinary gastric catarrh was
at first considerable, subsequently its true character was quite apparent.
The good effect of the subcutaneous injection was very evident. I have
used it in a similar case, in one of palpitation and prsecordial uneasiness,
and in one of asthmatic dyspnoea with decided advantage. In all these the
remedy was applied as near as possible to the apparent seat of the distress,
and I think this is not a matter of indifference. The patient in the above
case had taken tr. opii ttl vj ter die for three days without relief previously,
which shows that it cannot be merely the absorption of a certain amount of
the drug into the circulation which produces the beneficial effect. The in-
fluence of a remedy introduced into the parietes of a serous cavity upon the
subjacent viscera is I confess very difficult to explain, but not more so than
that of leeches and blisters similarly applied, which I think cannot be con-
tested There seems some reason to think that the nerves distributed to the
parietes of a serous cavity are co-ordiuated in a considerable degree with
those of the contained viscera, so that an impression made on the external
affects through the centres the internal. I cannot omit a remark as to the
cruelty of the Poor-law medical arrangements, which oblige a poor ague-
stricken peasant to walk twenty miles a day to get a supply of a remedy'
which is needful to cure him. Why do not the unions keep their own dis-
pensaries and exempt their medical officers from all the mere mechanical
work of dispensing medicines? If the system is not a sham, the deserving
poor ought to have what is needful, and it ought not to be a matter of
question to the medical attendant whether he can afford to give an expensive
remedy or not. His remuneration should be for his skill, and with the pro-
viding of drugs he should have nothing to do.

No. 134. — B. J., m., set. 52, ad. July 27th. Ill seven days. Is suffer-
ing from pain under the right ribs, which comes on unless he eats very
sparingly. It is very severe, extends towards the back, is sharp and prick-
ing. Liver not at all enlarged. Epigastrium and all the adjacent region
covered with marks of leech-bites. While in India he was bled from the
arm thrice, had seventeen dozen leeches applied, and took two hundred and
five grains of calomel, presumably for hepatitis. P. weak. T. clean. No fever.
Urine of good colour. Eyes clear. Livernot at all enlarged. A blister to the
painful part; pot. iod. and prussic acid were of no benefit, but liq. opii sed. n\, x
injected subcutaneously into the painful part took all the pain away, and
when I saw him three months later he had had no recurrence of it. It
caused, however, very great sickness. He was liable to gout. I do not know
whether this was a gouty neuralgia, but it is clear that it was effectually

17

258 ABDOMINAL NEUROSES.

quelled by the injection. Possibly there are some cases of supposed liver
disorder which might be well treated by the same means. I have placed
this case next to the preceding as illustrating the efficacy of the same mode
of treatment. It is I think a valuable means, but certainly should not be
used except in cases of rather severe pain on account of the troublesome
sickness it is apt to produce.

The following are instances where the vomited matters were
peculiar.

No. 135. — E. S., set. 36, f., of rather sanguine habit, ad. May 11th.
Affected with pityriasis all her life. At the catamenial periods, which occur
regularly, and the intervening fortnights she has copious vomiting of stuff
like brown water, which lasts for twelve hours, and is preceded by violent
headache. In the intervals she is tolerably well. Digestion pretty good.
Very apt to take cold. No rales in lungs posteriorly. Is worse after any
exertion. Functions in good order. Lives at Chiswick near the river, in
an open meadow. A week later the urine was found exceedingly pale,
aqueous, and non-albuminous. Bi-weekly doses of calomel with uitro-
muriatic acid and taraxacum were given for five weeks without avail. She
described herself as suffering with a sense of dreadful weight round the
chest for several days before the vomiting came on. On June 7th she
brought up much thick stuff like brown phlegm. B. relaxed, as they always
are in warm weather. Strychnia, quinine, opium, arsenic were now given ;
at a later period iron was substituted for the latter. She improved steadily
under this treatment, and was discharged apparently quite well Aug. 27th.

Remarks. — I read this case as one of periodic congestion of the stomach
issuing in exudation of bloody fluid, which became darkened by the gastric
acid. The result of the treatment proved that the pathological condition
was one of nerve-disorder, and not of hepatic congestion and obstruction.
The cause of the nerve-disorder is obscure, but the locality of her residence
affords some ground for suspecting the operation of malaria. The concur-
rence of severe head-pain and paralysis of the vaso motor nerves of the
stomach deserves to be noted.

No. 136- — E.T , set. 35, f, married, five children. Of rather sanguine aspect.
Ad. Feb. 9th. Ill one month. Has some cough and spits much blood (a
teacupful in one day), and some phlegm. The blood comes up with nausea,
but no vomiting, and is of a very bright colour. This hemorrhage has beeu
going on the whole month that she has been ill. The first of her illness
was that she felt extreme debility, and fainted several times a day. About
eight days later blood came up. She has copious cold sweats at night, and
feels very shivery in the morning. P. soft. B. costive. Catamenia were
delayed a week when the blood first was brought up. Chest deformed, right
front flattened^ there is right lateral curvature. No dulness aujwhere, but
weak breathing all throughout both lungs. Some epigastric tenderness.
She always experiences extreme exhaustion a quarter of an hour after
taking food; it lies heavy, but does not cause much pain. She contin-
ued under observation till April 20th, having lived part of the time in Pad-
dington instead of Walworth, where, her home was. The former locality
agreed much better with her than the latter. The treatment consisted of
quinine, opium, iron, and strychnia variously combined, and had a mark-
edly beneficial effect. G-astric hemorrhage recurred several times, but she had
none for the last three weeks of her attendance.

ABDOMINAL NEUROSES. 259

Extreme weakness was a prominent symptom, attended frequently with
what she termed faintings. These I believe from what T witnessed of them
were rather leipothymic than syncopal. There was apparent unconscious-
ness, but not the same loss of muscular power which occurs in syncope, nor
the same pallor of face. The presence of gastric ulcer must be considered a
probable cause of the hemorrhage. My own opinion, however, is that ulcer-
ation did not exist, or if it did, that it was not the cause of the symptoms.
The bleeding I look upon as analogous to epistaxis, and as proceeding from
active congestion of the capillaries of the mucous surface. For (1) it is
proved by Dr. Brittan's case, v. Brit. Med. Journ., April 2, 1859, that
copious bleeding may take place from the stomach without any ulcer, and
without obstruction to the venous current : (2) The peculiar and extreme
debility was not consecutive to and produced by the loss of blood, but may
be considered rather as its cause. By affecting the vaso- motor nerves of
the stomach it produced the active congestion. The cause of the debility
itself was probably some malarious miasm generated at Walworth, no
unlikely place for such an occurrence. (3) The treatment was not such as
was likely to benefit ulcer, at least while it was extending.

I will refer here to a similar case which I have recorded at length
in the Assoc. Journ.^ 1856, June 7th and 14th, in which a weekly
female, whose heart and lungs appeared sound, had various symptoms
of aguish disorder, with frequently-recurring hsematemesis and ex-
treme debility. With quinine, iron, country air, and rest she im-
proved much, and recovered at last after a voyage to Ireland. I
saw her recently in good case. A severe relapse was induced on
one occasion by her resuming work while too weak for the exertion.
The h^matemesis in this case was more a kind of frequent oozing of
blood than an actual gush. Once or twice, however, pretty free
bleeding occurred. I quote from my remarks the following. Re-
jecting the hypothesis of organic disease as wholly inadequate to
account for the symptoms, I observe that the view of aguish disorder
being the " grundleiden" is the only one which can explain the
phenomena, and it does so fully. The system was under the influence
of a depressing poison operating primarily on the nervous organs.
This caused the neuralgia, the toothache, the cerebral disorder re-
sembling intoxication, the bewildered feelings, the forgetfulness and
loss of sight by its action on the cerebro-spinal system; while its
action on the sympathetic and vaso-motor nerves was attested by
the hsematemesis, the syncopic attacks, the aguish paroxysms, and
the epigastric sinking. The periodicity of the hsematemesis and its
being checked by quinine testify to its peculiar character. The
immediate relapse on recommencing work is exactly what is observed
in neuralgia and other nerve disorders ; — the symptoms, which re-
main in abeyance during rest when the nerve-power is not expended,
are speedily reproduced when exertion consumes the yet too scanty
stock of strength. In inveterate cases such as this the influence of
a pure and bracing air is absolutely essential to cure. Drugs seem
to fail partly from actual deficiency of the vital (radical) forces of
the system. Another case came under my observation in which

260 ABDOMINAL NEUROSES.

haematemesis in small quantities went on for about six months, re-
curring at short but irregular intervals, and continuing for several
days at a time. It was associated with severe pain of one knee and
great nervous depression. After the ineffectual application of
several blisters and much medication amputation of the limb was ad-
vised by a hospital surgeon, but the patient declined. No astringents
had any effect in arresting the hemorrhage, which at last ceased
under the use of carbonate of iron, and the pain in the knee at the
same time became easier, so that she was able to move about with a
crutch after having been for months confined to bed. The knee
was never swelled, nor did it present to my eye much appearance
of organic disease.

No. 137.— J. W., m., »t. 38, ad. July 2d, 1857. Ill since last Christmas,
worse last three mooths. Suffers with pain after food, most after vegetables.
Formerly the pain lasted about four hours until vomiting set in and then
was relieved. Now for the last fourteen days he has had vomiting daily in
the morning from 3 to 4 A. M., and about 9 P. M. The vomited matters
are grayish and frothy, and have contained sarcinse. Is sometimes quite
free from pain when his stomach is empty. No tumour or anything morbid
to be discovered in abdomen; no epigastric tenderness. Heart and lungs
tolerably sound. Urine thick and passed with straining, and pain felt about
the crest of the ilium. Is losing flesh and getting weak. B. open ; when
they were confined some time ago he was better, and had less sickness.
Has had hyposulphite of soda without benefit, besides various other remedies.
I examined the vomited matter at this date and again September 24th, and
on both occasions found sarcinae in abundance. He remained under ray
care till October 1st, the symptoms recurring at intervals. Generally
towards night flatulence would come on to a considerable extent, and be
followed sooner or later by vomiting. Occasionally the flatus passed away
per rectum, and once was attended with sudden purging. The gastro-in-
testinal disorder was evidently no ordinary indigestion, it seemed to be to a
great extent independent of taking food. None would occur for several
days, and then an outburst would take place. It was in this respect somewhat
like the group of symptoms produced by obstruction of the pylorus, but the
sequel negatives the idea that there was any such organic lesion. When he
came under my hands he had already been treated most judiciously by Dr.
Vernon, who sent him to me, and I saw only one way of proceeding left
open to me, which was to deal with the malady as rather the result of failure
of power, than as a substantive disease. It seemed possible that if the inner-
vation of the general system and of the stomach in particular could be im-
proved the production of sarcinae and the vomiting might be materially
checked, if not arrested. Whatever part the sarcinae play in modifying or
aggravating the disease with which their occurrence is associated, they are
in all probability rather accidental than essential. They are found in avariety
of conditions, in ulcer, in pyloric obstruction, and simple disorder of secre-
tion, and in fact are probably developed like other fungi where the higher
organic life is waxing faint and feeble. On this view then I treated his
malady as a paralytic neurosis with quinine, iron, opium, and strychnia, the
quinine being increased up to gr. x ier die, and the strychnia to gr ^q.
The result was satisfactory; the attacks of flatulent disorder, of pain, and of
vomiting became much less frequent, and he gained flesh and strength.

NEUROSES OF THE URINARY ORGANS. 261

He was still however subject to recurrences when he ceased attendance {ut
mos est of hospital esterns). I hunted him up however in April 1859, and
learned from his wife that he was quite well and had been so a long time;
** had been nicely" all the last year (1858). After he ceased attending at
the hospital he had no further medical treatment.

I have pretty well anticipated any remarks I might have to make.
The moral of the case is that it may be well worth while to treat a
general condition rather than a particular prominent symptom. It
may also be added that there seems some ground from this as from
othercasesto think that the good influence of acourseof treatmentmay
show itself long after its discontinuance, perhaps even more markedly
than 'at the time of its being in force. Persons who have gone on
a tour, or visit to some distant place, not unfrequently continue to
improve in health after their return home.

CHAPTER XXXI.

NEUROSES OF THE URINARY ORGANS.

The urinary organs seem to be much less liable to neuralgic
affections than the digestive. They are, however, by no means
exempt, and some of the neurotic disorders aifecting them are ex-
tremely severe and intractable. They have their location mostly
in the viscera, or rather in the nerves distributed to them. Rom-
berg, however, justly describes the lumbar region of the cord as
being often implicated, and states that venereal excesses (which
exhaust this nervous centre) often are the cause. He gives no cases.
In those I have met with the neurosis has been as elsewhere
generally either of a rheumatic or simple kind. The following
instance was evidently the former: —

No. 138. — Gr. W., m., set. 38, ad. October 29th, ill nine days. Complains
of pain in micturition of an aching kind, and felt mostly at the end of the
act. Has pain also in hypogastrium varying in severity at different times.
Micturates often, has to rise once or twice at night. Urine clear, no dis-
charge at all. Pot. iodid. gr. vj with a little henbane daily for a week
cured him.

No. 139. — Gr., get. 30, f., seen February 19th, suffering with some
irregular action of bowels, but chiefly with irritation of bladder and frequent
micturition, and feeling nervous and weak. With citrate of iron and
quinine + tr. nucis vom. + liq- opii sed. she improved materially in the
course of a month, though some dysuria still continued. May 19th. She
came under my care again for very severe dental neuralgia, which came on
just after a double tooth was drawn sis weeks previously. The pain was
incessant, but worse at night, and had deprived her of rest for many nights.
She had, however, felt " bodily well" since the pain had been so severe.

262 NEUROSES OF THE URINARY ORGANS.

With quinine + iron she improved speedily, and no complaint was made of
the dysuria.

In this case the severe dentalgia, which evidently was not de-
pendent on diseased teeth, serves as an exponent of the nature of
the dysuria. Both in fact were simple neuralgias, and the latter
seems to have heen absorbed by the former. Bourguignon' has
specially described neuralgia of the bladder, and states that it is
produced by exactly the same causes as give rise to other neuralgias.
Rheumatism is the most frequent of all, especially when induced by
chilled feet. The neck of the bladder is the especial seat of the
neuralgia, and the symptoms are pain, frequent calls to urinate, and
tenesmus (spasm) of the sphincter. If the disorder is of rheumatic
origin, the urine generally deposits lithates; if it is not, the urine is
copious and clear. Long continuance of the neuralgia may lead to
paralysis of the muscular coat of the bladder. In aggravated cases
cerebral and spinal symptoms ensue. In the matter of treatment
he recommends sedatives locally and internally, alkalies if the urine
is over-acid, tonics, and electricity. Hamon recommends superficial
cauterization of the skin of the hypogastrium with nitric acid.

Dr. Behrend reports the following interesting case :^ —

No. 140. — A lady, set. 30, without family, suffered from May, 1857, with
great irritability of the bladder, compelling her to rise from three to eight
or even more times in the night. The urine then was pale, insipid, but
otherwise normal, except that it was two or three times as copious as in health.
She had lost flesh, and suffered much from thirst, headache, and nausea,
especially on rising in the morning. Her spirits were much depressed.
During the day there was no little irritability, and the quantity of urine
was nearly normal. Tr. ferri inuriatis, valerian, mineral acids, liquor
potassae, sea-bathing, change of air were of no avail, but belladonna given
ultimately in a dose of gr. 2 of the extract in the morning, and gr. j at nine
P. M. effected speedily an almost perfect cure, which remained permanent,
although the remedy was at once discontinued after it had produced its
physiological effects. The disease had existed sixteen months before the bella-
donna was given. The vesical hypersesthesia in this instance seems to have
extended to the renal nerves and to have given rise to the increased flow of
watery urine. Hysterical hypersesthesia has the same effect we know.
The nocturnal character of the neurosis should be noted.

In the following instance the neurosis was probably of toxic
origin : —

No. 141. — J. F., set. 57, m., gardener, ad. September 4th, 1855.
Rather short, emaciated lately. Has had gout seven or eight times, not
every year, but nevertheless declares that he has always had " the greatest
of health." During the last three weeks his urine has been constantly run-
ning away both by night and day. Appetite and digestion good. No thirst.
Urine quite clear, light-coloured, rather highly acid, not albuminous, nor
saccharine. He drinks a great deal of tea; takes tea at dinner. Bladder not

1 "L'Union Med.," 1861, Nos. xxxiii., sxxv.

2 "Lancet," June 25th, 1859.

NEUROSES OF THE UHINARY ORaANS. 263

distended. He remained under treatment till April 2d without any real
amelioration of his urinary incontinence. I gave him ammonia, bark, quinine,
iron, strychnia, ol. morrh., tr. lyttae at night, arsenic, ainc, opium supposi-
tories, beliadonoa -|- quinine, and cubebs. The belladonna did more good
than anything else. About April 5th his right hand was attacked smartly
with rheumatic gout, and immediately his vesical disorder entirely ceased,
and had not reappeared when I last saw him June 11th. Gout is well
known as a tormentor of the nerves, and Cullen and Prout both allude to
gouty irritation of the urinary organs. Strangury or spasm of the neck of
the bladder, or irritability of the detrusor, seems however to occur more
frequently than paralysis. In my case the condition was certainly chiefly
paralysis of the sphincter. He was galvanized twice, but without advantage.
No. 112. — Mrs. A., aet. 40, seen July 11th, complaining of increased
frequency of micturition with a sense of burning afterwards about umbilicus j
this chiefly troubles her in the early part of the day, not at night. Health
pretty good. Urine in fair quantity, full-coloured, sp. gr. 1027, deposits
much octohedral oxalate, and gives some spontaneous crystallization with
NOj. I prescribed nitric acid + liq. opii sed. + tr. and infus. lupuli. In
five days she was much improved, and the condition of the urine had changed
remarkably; it was pale, aqueous, sp. gr. 1008, alkaline, and free from
oxalates or any other deposit ; its quantity was not observedly increased.
The dysuria did not reappear.

In this case the vesical dysaesthesia was probably associated with
exaggerated renal destructive assimilation, both conditions being
dependent on nerve paresis, and both being amended by the same
tonico-sedative remedy. Oppler's experiments' are tolerably con-
clusive as to the active part taken by the kidneys in forming the
solid urinary excreta. If we consider with Brown-Sequard that by
paralysis of the vaso-motor nerves the vital actions of a part are
increased, in consequence of the unusual supply of arterial blood it
receives, we can understand that the urinary solids might be notably
augmented in a condition of paresis of the renal plexus. The in-
creased excretion of urea which occurs in low fevers may be ascribed
in part to the same cause, the renal being involved with the other
nervous districts in the general paresis. That there was a material
difference in the urinary solids on the two occasions noted in the
preceding history can hardly be doubted, and almost as little that
the change effected was the result of the medication. In a paper
in the Brit. Med. «/., Oct. 12th, 1861, I have given an instance
where the amount of urea and phosphoric acid during twenty-four
hours was ascertained in the condition of baruria, in the normal, and
while the patient was under the influence of nitric acid and opium. In
the first the amount of excreta was more than four times as much as
the lowest observed in the latter condition. The coincidence is
worth observing, and can scarcely be without significance that the
same remedy is very efficient in certain asthenic bronchial and in-
testinal catarrhal fluxes. In choleraic disorder it has been much

* Virchow's "Archiv.," vol. xxi. p. 3; "Sjd. Soc. Y«ar-book," 1861, p. 219.

264 NEUROSES OF THE URINARY ORGANS.

relied on by some practitioners. Its action as an astringent tonic
arresting destructive metamorphosis must surely be tbe same in all
cases. There is nothing specific about this remedy, as in the fol-
lowing case strychnia answered the end much better.

No. 143 — H., m., set. 35, seen July 15th. He complained of aching
uneasiness in the loins, which he had had since the previous winter, with
great general debility and nervousness. The hyperaesthesia was still very
considerable. Appetite poor. He was chiefly troubled by a nervous feeling
referred to the bladder leading him to imagine that he wanted to urinate
though he had no real call to do so. If he was at all hurried, he could not
urinate at all. This vesical dyssesthesia he had had for years. The urine
was highly acid, sp. gr. 1036, contained an excess of urea, and deposited
lithates and some oxalates. Nitro-muriatic acid+ liq. opii failed to benefit,
but strychnia eifected a cure. The urine on Aug. 6th, after he had taken
the strychnia five days, was of sp. gr. 1021, of normal colour, and deposited
no uric acid nor oxalate in twenty-four hours. The next year he had a
return of the same symptoms, and strychnia with citrate of iron and quinine
was effectual. An occasional opium suppository was also useful in calming
the vesical uneasiness.

In this case there was a condition of general hyperaesthesia which
did not exist in the former, but which is evidently only "un degre
de plus" of the same disorder. The same remarks apply to both.

No. 144. — Mr. A., aet. 27, seen Aug. 25th. Has lived until last three
years a gay life, and committed venereal excesses, but is now steady. Has
had syphilis. Is pallid, thin, weakly, and nervous. Has had indigestion,
but this has ceased. B. are irregular, either loose or confined. Urine full-
coloured, sp. gr. 1028, crystallizes with NO5, deposits a little mucus, no
oxalates, not albuminous. There is a slight urethral discharge. Some long-
standing eczema of the scrotum. He was ordered at first (before the urine
had been examined) arsenic -f- tr. cinchon. with ol. morrh., and ungt. zinci
+ hydr. uitr. oxyd. to the eruption. In a week the eczema was better,
but he thought his general state worse. I gave him then pills of argenti
nitrat. gr. J -f opii gr. J + extr. coloc. co. gr. j ter die. On Sept. 10th he
was decidedly better, his countenance clearer and brighter, his urine of lower
sp. gr. and giving a less crystallization of nitrate of urea. Sept. 15th. His
urine is pale, sp. gr. 1013, does not crystallize with NOg. The quantity is
about Oij, the same as it was on Sept. 10th ; at first it was about Ojss. He
feels and looks much better, has more spirit and is more cheerful, his diges-
tion however is weakish. He tells me that when he fii-st came to me he had
such depression that he used to feel inclined to cut his throat.

Dr. Sieveking related once to me the case of a clergyman in a
state of hyperaesthesia and complete loss of tone, passing 30 to 40
oz. of urine daily, which contained so much urea as to solidify with
nitric acid. Quinine given to the amount of 30 grains a day reduced
the sp. gr. from 1030 to 1010, and greatly improved his state and
his sensations. I am aware that the existence of such a disease as
baruria (Prout's azoturia) is denied by some excellent authorities
(Parkes has never seen such a state), and that it requires to be care-
fully distinguished from mere relative excess of urea. Also, except

NEUROSES OF THE URINARY ORGANS. 265

in the one case quoted above, I have not proved by actual figures
that there was excessive excretion of urinary solids.' Still I am
quite satisfied from repeated observation that if, in connection with
general or vesical hyper^esthesia and debility, we find the urine of
high sp. gr., non-saccharine, crystallizing with NO5, or depositing
lithates or oxalates copiously, we may confidently expect that an
alteration in the state of the urine without much increase of quantity
will coincide with remarkable improvement, and that this change
will generally be effected by opium with some of the milder tonics
rather than by the stronger. Of the value of this clinical fact I
have no doubt, but I am not so sure of the correct interpretation of
it. That the renal disorder is not a necessary result of general
nervous prostration is perfectly certain, as the urine in such states
is often very pale and light. Still my experience points very much
to some debilitating cause as the prime motor of baruria. Dr. Prout
considered abuse of the sexual powers as principally, and generally
such causes as enfeeble the vital powers and more especially the
spinal nerves as producing baruria. In two females where the urine
was in this state there was extreme hypergesthesia and debility, and
besides such casual conditions as would give, rise to general pros-
tration. On the other hand the great benefit to the general health
which coincides with an alteration in the urine indicates the cessa-
tion of some debilitating morbid action, and this can scarcely be
anything else than the excessive renal excretion. If it be objected
that the amount of loss to the system in this way can scarcely be
material, and would be easily compensated by a little increase of
diet, it may be replied that there are several similar instances, in
which a chronic discharge of no great amount produces very con-
siderable debility. I am disposed to think that the debility is both ,
cause and consequence ; that by producing paresis of the renal nerves
it sets up the morbid excretion, and is subsequently itself increased
by the drain to the system occasioned thereby. There is a decided
tendency in the urine passed by patients suffering under baruria to
deposit oxalate of lime, and in some instances the crystals are very
large and numerous. Lithates are often present with the oxalate
or may replace it, and the view taken by Prout and B. Jones that
the two deposits are of the same general nature seems to me well
founded. It may be remarked "en passant" that there is perhaps
no instance where cell-tissue and vessel are more distinctly ruled by
nervous influence than this of the kidney. The common result of

' The following case, which I have lately met with, seems but little open to question,
A gentleman, Eet. 45 about, very antemic, but strong and capable of much exertion,
a small meat-eater, weighing 9 stone, passed in 24 hours 33 oz. of urine which crys-
tallized into a solid mass with half its volume of nitric acid. The total amount of
urea was 673.88 grains, of uric acid 7.68 grains. The urine contained a very little
albumen ; it had recently been more considerable. There was no sign of renal con-
gestion, no febrile movement. The eyelids had been a little puffed. His parents
had been very gouty, but he never had any attack. He is intolerant of tonics and of
even very minute doses of opium.

266 NEUROSES OF THE URINARY ORGANS.

an hysteric attack shows clearly that the capillary membranes of
the Malpighian tufts must be remarkably altered for the time so as
to allow of a greatly increased transudation of aqueous liquid, while
at the same time the secreting action of the epithelium of the cor-
tical tubes is much diminished. It is worth mention that a small
dose of opium has in some persons very much the same eifect, while
quinine in full doses has an opposite. '

The nocturnal incontinence of urine so common in children I
believe to depend upon an hyper-excitability of the vesical nerves,
in consequence of wljich the stimulus of even a small quantity of
urine causes contraction of the muscular coat. Belladonna acts
here as a sedative, just as it does in the case of the pulmonary nerves.
Some tonic with ol. morrh. will also generally be found advisable.
Trousseau takes just the same view; he gives belladonna in increasing
doses if the disorder does not yield, up to even gr. iv of the extract,
at night; and continues it for three, four, or five months, then grad-
ually diminishes the dose for two, four, six, or even ten months,
until the morbid habit is fairly broken. If the incontinence is
diurnal as well as nocturnal, he considers that the sphincter vesicae
is paretic, and administers strychnia.

No. 145. — A., set. 45, m., has suffered for years with symptoms of neuro-
lysis and obscure remittent fever. Strychnia has been of great service to
him. He was in all respects as well as usual when late one night he was
much alarmed by finding his urine very bloody ; he came immediately to me,
and passed in my room a little which was very full of blood, the red globules
being diffused through the liquid, and not forming casts. No epithelium
was present. After a dose of tannin + opium that night the next day's
urine was smoky, but much less bloody, it deposited a brownish-red sediment,
.consisting of red globules and numerous large octohedra of oxalate of lime.
The supernatant fluid was red, clear, sp. gr. 1029, and notably albuminous.
The same day at 1 P. M. at my house he passed urine which was pale and
perfectly clear, and free fi-om any deposit or albumen, sp. gr. 1013. The
microscope detected nothing. The region of the bladder was quite soft and
painless j he had no pain anywhere except a very slight uneasiness at the
root of the penis. No relapse has occurred, though he has since married
and travelled about.

From the absence of any indications of calculus in the kidneys or
bladder, from the speedy cessation of the hemorrhage, and the emi-
nently neurolytic diathesis of the patient, I conclude that most prob-
ably the hemorrhage was not dependent on any organic lesion, but
was essentially analogous to epistaxis, and depended on an acci-
dental congestion of the vesical capillaries from a freak of vaso-
motor nerve paresis. Watson alludes to cases of hsematuria occur-
ring in connection with ague. Prout notices the much more frequent
occurrence of hgematuria in certain years than in others, especially
in those succeeding the epidemic cholera. It is probable that a modi-
fication of the choleraic miasm may produce this hemorrhage by
paralyzing the renal nerves. I have seen a pretty copious hemor-

NEUROSES OF THE URINARY ORGANS. 267

rhage from the bronchi of one lung occur in a similar way at night
in a man who never had before nor has had since (though five or six
years have elapsed) any symptoms of phthisis, heart disease, or
aneurism.

The following case of sunstroke narrated by M. Beaupr^^ seems
to me very proving as to the effect of sudden nervous prostration on
the vesical and other capillaries, and even on the tissues. Towards
the end of July a soldier, set. 26, who had previously enjoyed per-
fect health, was brought into hospital, having by his comrades' ac-
count suddenly fallen senseless on the rampart where he had been
two hours on guard exposed to the whole power of the sun; in that
condition he was found when they came to relieve him. His ex-
tremities were warm, his face pale and leaden ; there was total loss
of motion and feeling; black dissolved scorbutic-like blood flowed
from the nasal fossae. The cavity of the mouth was filled with blood,
and all the lining membrane was checkered with livid, scorbutic-
like spots. A litre and half of black blood mixed with urine was
drawn off by the catheter. The pulse was small and very feeble.
Death occurred in six hours. On dissection the bladder was found
filled with putrid fetid blood ; the whole extent of the mucous mem-
brane of the nose, pharynx, oesophagus, stomach, intestines, and blad-
der, presented the same livid spots as the inside of the mouth ; the
putridity of the corpse rendered quick burial necessary. This record
shows that powerful insolation acting on the brain may destroy the
tone of the capillaries in numerous parts of the body, and so impair
the consistence of their walls that they can no longer retain their
contents. This effect must be produced through the vaso-motor
nerves which are involved in the general paresis. There is a good
deal of resemblance between this case and the one of burn recorded
at p. 68 as well as those of intestinal hemorrhage pp. 268, 269.
In all prostration of nervous power led to effusion of blood. It is
not improbable that the extreme congestions found in some cases of
heat apoplexy depend, as in the above, on complete loss of capillary
tone, and that therefore the term apoplexy is correct, though not in
the sense that the congestion or effusion is the cause of the seizure.
In all cases of vaso-motor paresis there is probably more or less im-
pairment of the tone of the capillaries as well as relaxation of the
arteries, so that we can easily understand when the heart's action
is excited, as in the hot stage of remittent fever, how great is the
risk of extravasation. The capillary alteration is however "ua
ddgre de plus" beyond that which relaxes arteries.

' '< Treatise on Cold," p. 11.

268 NEUROSES OP THE LOWER INTESTINE.

CHAPTER XXXII.

NEUROSES OF THE LOWER INTESTINE.

The rectum is by no means a common seat of neuroses, in this
country at least. The only forms I have myself met with, and these
perhaps rather belonged to a higher part of the bowel, consisted in
serous, flatulent, or bloody discharges occurring under circumstances
which made their dependence on nerve disorder highly probable.
Thefollowing case is a good example.

No. 146. — C. R., set. 23 (?), seen July 3d. Has been invalided and sent
home from India on account of dysenteric diarrhoea; has now been at home
about a year. The diarrhoea has almost ceased under Sir R. Martin's treat-
ment, but the bowels are very easily disordered; a glass of bitter beer will
act as a purge. The motions are apt to become lumpy and pale. The chief
trouble he has now is great flatulence passing per rectum; it will come on
quite suddenly and be very troublesome for some time ; it mostly occurs
some time after dinner. He is pallid and has lost much flesh. During a
recurrence of dysenteric diarrhoea while under my care the flatulence quite
ceased. Some months later the neurosis came earlier in the day, after
luncheon, and not after dinner. He would then have uneasiness in the
bowels, some tendency to relaxation, and pass a lot of wind. Still later,
when the fltitulency had almost left him, he found that it always returned
whenever he became weak and prostrate, which was the case now and then.
The last note I have is that the flatulent disorder came on every night ex-
actly at 10 P. M. and lasted fifteen minutes. He could take beer and even
champagne well, and had materially gained in strength. The most efficient
remedies were pills of quinine -f opium + creasote + pip. nigr. ter die,
tannin + opium in pills, pepsine wine, and abundant out-door exercise.

I believe it is considered by some of our best authorities as highly
heretical to hold that mucous membranes can secrete gas. I must
confess that I cannot explain such a case as the above without ad-
mitting that such secretion may actually take place. In a very
similar instance, but of much shorter duration, towards the termi-
nation of the disorder, the diarrhoea, which had been markedly
paroxysmal, gave place to quite similar bursts of gastric or intestinal
flatulence. It seems as if one might almost speak of a gaseous
diarrhoea.

No. 147. — Tr., £et. 40 (?), a fine-looking, well-conducted but not very
strong soldier, acting recently as drill-sergeant to a volunteer corps. Was
in the Crimea, had good health all the time. Never had any kind of fever.
Latterly has lost much flesh and got very weak. Lungs rather emphy-
sematous, otherwise sound. Heart sound. He suffered first with sudden

NEUROSES OF THE LOWER INTESTINE. 2G9

attacks of palpitation and great debility; subsequently he had symptoms of
gastric catarrh and paroxysms of severe gastralgia. While improving he
began to pass blood per avnm; the first day he passed Oij, he thinks, and
continued to do so in varying quantities for some days. The abdomen was
full, soft, resonant all over, but less so in the left hypochondrium than else-
where ; the hepatic dulness was diminished in extent. A feeling of weight
and pain which he had had in the lower part of the abdomen ceased after
the bleeding. He had no piles. Under the use of lead 4 opium the bleed-
ing ceased, and with quinine and change of air he recovered. His health
has since been fairly good, and he has only once had a very slight recurrence
of bleeding.

Remarks. — The cause of the hemorrhage in this instance is doubtful,
but I think one may exclude piles, dysenteric and tuberculous ulceration,
and malignant disease. Had any of these existed there would almost cer-
tainly have been prior symptoms, and the hemorrhage would have recurred.
On the other hand, the existence of marked neurolytic disorder and the
previous exposure to malaria make it not improbable that congestion of the
lower part of the colon or rectum may have given rise to the bleeding.

No. 148.~S. Sp., f., ast. 27, ad. Sept. 14th. During the last week has
been suifering more or less pain in stomach (abdomen probably) accompanied
by diarrhoea of which she took no notice, was purged yesterday several times,
and early this morning was seized suddenly with severe pain in stomach
with somewhat violent retching. On her admission she was cold, surface
clammy ; she complained of intense pain in the abdomen. P. weak and
frequent. Ate some plums and apples last night.

Galomelanos, camphorse, opii, capsici, aa gr. ^, ft. pil. post sin(j. sedes
liquid. Mist. pot. citrat. eflFerv. §j. Acidi hydrocy. dil. n\,v '2dis horis.

The sickness was arrested, the next day she passed a motion containing
large coagula of blood. 16th. Passed more blood in motions last night,
much pain in abdomen, increased on coughing. Twelve leeches were applied
to the belly and relieved the pain very much. She took also the above pill
ter die 19th. No blood last two days in stools, only some feeling of sore-
ness now in abbomen : has begun quinine. She went out well.

Remarks. — This case occurred during the prevalence of epidemic cholera,
and was clearly the result of the miasm. It is impossible to say what were
the causes which determined the occurrence of hemorrhage rather than of
serous discharge, but it is evident that there must have existed great con-
gestion of the mucous membrane, probably of the large intestines Extreme
capillary congestion and extravasation of blood were ob.served by Reinhard
and Leubuscher in some fatal cases especially in the ileum. One part at
least of this congestion must have consisted in dilatation of the arteries of
the mucous membrane, and another in loss of tone of the capillaries, both
probably the results of nervous paralysis. That the choleraic poison acts
especially on and through the nervous system is, I think, unquestionable.
The remarkable and peculiar depression, the algide symptoms, the cramps,
the sudden prostration and death occurring sometimes without any diarrhoea,
all testify to this fact.

The following case from Torti is well worth perusal in reference
to this subject.

No 149. — A garrison soldier of our city in the third paroxysm of a tertian
fever passed a dejection extremely blackish, as it were made up of blood

270 NEUROSES OF THE LOWER INTESTINE.

partly coagulated and partly dissolved. It resembled somewhat a copious flow
of haemorrhoidal blood; but the black colour, and its being thoroughly mixed
with excrements of softer consistence, showed that it came from higher up.
The excretion was also (at times) clear and unmixed with feces, quite like
the black blood called by the ancients atrabile. Yery copious was this dis-
charge, frequent, and violently ejected, the countenance at the same time
became Hippocratic, the extreme parts cold and livid, the whole body corpse-
like, the pulse almost abolished, while the patient lay buried rather than
swimming in a pool of this foul fluid from which he endeavoured to free
himself with vain efi'orts and restless tossing to and fro. As quickly as
possible all the sacraments of the Church were directed to be administered,
and then the Peruvian bark in strong doses, though almost without hope.
The next morning the patient was still alive but utterly prostrated, still
rather cold, and with a most feeble pulse. The use of the remedy is con-
tinued according to my practice in a smaller dose, and this alone and food
is prescribed. On the following day an exceedingly mild attack occurs, and
in it the pulse begins to rise (in force) and the body gets somewhat heated,
while there is no return of the black dejections. The patient advanced
towards health every day after, had no further relapses, and completely
recovered, the bark being continued by way of prophylaxis for some days.

There can be no question in a case of this kind that the hemor-
rhage was not the result of ulceration.

No. 150. — Mrs. A., set. 50, f, a finely-made florid person of highly nervous
temperament, but little strength. Her catam. have occurred every fourteen
days since girlhood. If she gets the least cough expectorates blood. Ten
years ago had copious hasmatemesis ; brought up a basinful. When young
has been bled many times without benefit. She had constantly-recurring
slight eczema, which did not yield to the usual treatment, and as she
appeared full-blooded I took on one occasion Jvj of blood from the arm.
It weakened her considerably for some time and did no good. She has
several times had copious bleeding per anum, which, as far as I could judge
from an examination I made during one of these attacks, did not proceed
from piles. There was diarrhoea at the same time and tenderness over the
descending colon. Tannin -|- opium with lead enemata arrested the hemor-
rhage, but it recurred at intervals a long time afterwards, and probably does
so still.

The circumstances which dispose me to regard the above case as
an instance of intestinal vaso-motor nerve paralysis are (1) the occur-
rence of hemorrhages from four different surfaces at various times ;
(2) the marked vrant of tone and nerve power; (3) the marked
plethoric aspect of the patient in spite of all the frequent losses of
blood ; (4) the good effect of strychnia, which she has repeatedly
taken with great advantage. It appears as if the quantity of blood
frequently became disproportioned to the retentive power of the
vessels, in consequence of which rupture and extravasation occurred.
The state of the system resembles that of the so-called " hgemophilic"
or bleeders. Besides the tendency to hemorrhage the only other
marked peculiarity is the hypersesthesia and nerve debility. It
may be an error to regard the vascular and nervous weakness as

UTERINE NEUROSES. . ^ 271

caiisatively connected, but there are certainly some grounds for the
opinion. Thus I have had eyidence again and again that cutaneous
purpura is essentially the result of debility and not of privation of
vegetables, and I have more than once seen extravasation of blood
take place under the conjunctiva solely as the result of neurolytic
prostration. Scurvy is said to have appeared among some American
troops, and to have proved fatal in some cases, which appeared to
be induced chiefly by ennui and home sickness. V. Amer. Med.
T., 1861, June 1st.

Mr. Ashton, in" his work on Diseases of the Rectum, thus describes
neuralgia in this situation. "The disease is most frequently met
with in angemic individuals in whom the nervous sensibility is gene-
rally excessive and often deranged. Females whose systems have
been depressed by monorrhagia, or frequent child-bearing, particu-
larly if the labours have been attended with violent floodings, are
liable to become the subjects of this disease, as well as of other forms
of neuralgia." The quality of the pain varies in diiferent persons
and at different times; it is sometimes constant, more often remittent.
As to its origin Ashton describes it as either reflex from some cause
of irritation in other parts of the alimentary canal, or as induced
by exposure to cold and damp, as in sitting on cold wet stones, or
by the influence of malaria. He relates an interesting case in
which the patient had been engaged harvesting in Essex, and had
been exposed to the night air. He complained of great pain at the
fundament occurring daily and continuing for some hours, not in-
duced or aggravated by defecation. No lesion of any kind was dis-
coverable. The local application of belladonna failed, but with
quinine he soon recovered.

CHAPTER XXXIII.

UTERINE NEUROSES.

The uterus seems to come in for a fair share of neurotic disorder.
This indeed might be expected not only from its functional im-
portance, and its extensive sympathetic connections, but from the
marked depression of nervous power with which its monthly evacu-
ation seems to be almost constantly associated. The commonest
form of dysmenorrhoea is recognized by Churchill and Tyler Smith
as neuralgia. Besides these periodic affections there occur more
continuous ones, which seem to be, however, of much the same
character. The usual causes of neuralgia affect the uterus as they
do other parts. Rheumatism, miasmata, and remote irritation play
the same part here as they do elsewhere. The afi"ection described

272 UTERINE NEUROSES.

under the name of "irritable uterus" appears to be a true hyper-
esthesia quite distinct from neuralgia as we have seen it to be in the
case of the stomach. Dr. Marion Sims' vaginismus appears to be
essentially a similar hy perse sthesia of the vulva. Common monor-
rhagia, not of organic origin, is evidently intimately connected with
vaso-motor nerve paresis, and is restrained eftectually by treatment
corresponding to this view. Sir R. Martin mentions the frequency
of uterine hemorrhage in females who have been long in India, and
refers it to weakening of the nervous and muscular power of the
organ by long exposure to heat and malaria.^

No 151— M. W., set. 25, f , ad. July 26th. Ill since her confinement
nine weeks ago. Suffers with pain round the lower part of abdomen and
dreadful bearing-down. The pain causes her to bend double when it comes
on; it is worse at night. Sometimes there are intervals of freedom from
pain for about two hours. No discharge. Uterus appears quite normal.
Appetite tolerable, but food lies heavy. Head giddy. Pulse not weak.
Urine very high-coloured and copious. She took for three weeks pot. iod.
gr. j + sod. carb. gr. xv + inf. gent. co. ^j ter die, and used an opium
and belladonna liniment. Under this treatment she improved very much,
and was then ordered ammonia, soda, tr. hyoscy., and dec. cinchon , which
she took until September 3d, and was then discharged well. The state of
the urine, the absence of marked prostration, and the efficient remedies
point out the rheumatic character of this hysteralgia.

No. 152.— E. N., f., get. 32, no children. Ad. October 28th, ill six
months. Suffers with bearing-down pains, but has no discharge. The pains
are aggravated at times, and she then passes a large quantity of aqueous
urine. At the catamenial periods the pains are much worse. Uterus
healthy. No pain in connection. No tenderness on either side of abdomen.
A crural hernia on right. In the course of her attendance she had throat
dyssesthesia for a time. She took citrate of iron and quinine -f tr. nuc. vom.
-|- spt. geth. chl. ter die for about two months and improved steadily and
satisfactorily. This case seems to have been one of simple uterine neuralgia.

No. 153. — A. S., f , aet. 18, ad. April 12th, ill three weeks. Has violent
pain at lower part of abdomen and bearing-down. Catamenial discharge

' There is an important passage in Virchow's " Handbuch der Pathol.," vol. i. p.
231, in which he states that on microscopic examination small solutions uf continuity
are actually seen to occur in the capillaries and small arteries and veins, through
which single blood-globules escape one after another, while the current goes on
uninterrupted within the vessels. If the gap in the vessel is larger the circulation
may be stopped in the vessel, and the current may set from all sides towards the
orifice. He states further that after the escape of a certain amount of blood the wall
of the vessel may be repaired, and the leak disappear. He does not state in what
tissue he has seen the phenomena. I have never witnessed anything of the kind ia
the frog's web, but I think nevertheless that it is extremely probable that the wall of
the smaller vessels does undergo modifications which make it permeable by solid cor-
puscles without its losing its consistence entirely, reducing it in fact to something like
a film of gelatine. Such alterations take place under various conditions in which the
vital power of the tissues is impaired, and among them I think prostration of nervous
power must be noted as one of the principal. The same influences which cause arterial
relaxation will often cause also leakage of the capillaries, and the same means which
prove remedial in the one condition avail also in the other. I believe that some
change of this kind in the smaller vessels occurs in normal menstruation, and the
relation of this process to lowering of nervous power seems to me unmistakable.

UTERINE NEUROSES'. 273

has continued for last three weeks, is brought on by any exertion. Ab-
domen soft, bears pressure very fairly. She feels very weak. B. regular.
She was ordered amnion, carb. gr. iv + liq. potass, arsenit. ttl iv -f inf.
gent. CO. 5j ter die. 19th. Pain so severe two days ago that she fainted.
Catamenia ceased. 22d. Is stronger, pain continues. May 6th. Is a great
deal better; the pain is felt only now and then. Pt. c. mist. ol. morrh. 5j
+ vini ferri 5ss his die. She did not return. In this case the affection
of the sensory nerves was complicated with paresis of the vaso-motor, and
as both disorders were amended by the same remedy it may be inferred, as
we have done previously, that they were "au fond" of the same nature. I
have recorded a case (v. Lancet, July 21st, 1855) in which paroxysm
of severe neuralgia of the face issued in actual extravasation of blood in the
eye and cheek. The pain would continue very severely for forty-eight
hours, then begin to remit, and at the same time a blush would appear in
the part which increased until there was actual effusion of blood.

Dr. Calien has recorded {Arch. Gener., Oct. 1863) two cases
showing the influence of ileo-lumbar neuralgia on the occurrence of
uterine hemorrhage, and remarks that the occurrence of congestions
and hemorrhages in neuralgias is certainly to be attributed to the
concernment of the vaso-motor nerves.

No. 154. — E. M., f.j 93t. 42, married, ad. July 16th, ill two years. Has
pain at nates on sitting' down, and in hips when walking. She cannot pass
urine or feces without pain, and has frequent calls to both evacuations. Is
never free from red discharge. On vaginal examination the os and cervix
are found excessively tender, so much so that it is impossible to ascertain
their condition accurately. Is very weak. Aspect very pallid and sunken.
Vaginal suppositories were ordered, consisting of opii gr. ij + extr. bellad.
gr. i, and pot. bromidi gr. x ter die. She continued under my observation
only fourteen days, but appeared to benefit by the remedies. This was in
all probability a case of hypersesthesia. Dr. Tilt records a similar instance
where a married female, set. 30, had been confined to bed for several months
by an excruciating pain in the back and in the lower part of the abdomen.
The pain was constant, but was much aggravated at the menstrual periods.
The womb was exquisitely sensitive, its neck swollen and slightly ulcerated.
After the inflammatory condition had been relieved by leeches, &c. the pain
persisted until vaginal suppositories of morphia gr. j — iij on cotton wool
were used, which cured the neuralgia. M. Aran adopts a similar pro-
ceeding.

In his excellent paper on Irritable Uterus {Lond. J. of Med.,
May, 1851) Dr. Mackenzie lays down that the disorder is rather of
sympathetic than of idiopathic character, the immediate cause being
reflected irritation having its origin in various organs with which the
uterus has intimate relations, but the predisposing being a defective
state of the blood inducing hypersesthesia of the nervous system
generally, and of the uterine nerves in particular. Spinal irritation,
gastro-intestinal disorder, gout and rheumatism, he seems to con-
sider as the principal causes of hysteralgia. From an analysis of
thirty-seven recorded cases he shows that the principal complications
are leucorrhcea and disorders of menstruation; the most frequent
18

274 CUTANEOUS NEUROSES.

antecedents are dyspepsia, mental anxiety, and weakening dis-
charges ; the concomitant affections are anemia, spinal irritation
and disorder of digestion. My own experience would lead me to
take rather a different view as regards the influence of reflected irrita-
tion in causing hysteralgia. Causes of the former in the alimentary
canal and elsewhere are abundantly common in my field of exj)e-
rience, but the special symptoms of the latter affection are extremely
rare. Leucorrhoea, menorrhagia, dysmenorrhoea are frequent enough,
but it is very rare to meet with uterine hypersesthesia, at least in a
marked form. The affection seems to me strictly comparable to
hypersesthesia in other situations, and it is very difficult to say
whether its essential seat is in the peripheral nerves, or in the cen-
tres. Dr. Tyler Smith has mentioned to me a case in which frontal
neuralgia and ague continued until puberty, and were then replaced
by "irritable uterus." In this case the nerve disorder was not of
reflex origin.

The treatment of menorrhagia not depending on plethora, or
organic disease, is generally very satisfactory. The patient is
directed after the flow returning at the proper time has continued
for three or four days to take tannin with acid, muriat. + liq- opii
sed. + spt. geth. chlor. in doses proportioned^ in frequency to the
amount of the hemorrhage. When the flow is arrested by these
means I give citrate of iron and quinine + liq^ pot. arsenit. ter die
during the intervals, and I usually find that their length becomes
gradually increased, while the duration of the discharge diminishes.
I am sure of the virtue of arsenic in such disorders, and I am rather
surprised not to see it mentioned among the remedies advised in
some works specially devoted to the diseases of women. There is
nothing specific or peculiar in this action of arsenic ; it is a powerful
nerve tonic, and as such induces a better contraction of the uterine
arteries. In his excellent paper on arsenic Dr. Begbie has specially
noticed its action upon the uterus, v. Edin. Med. J., 1858, May.
In some cases I have found strychnia -f tr. ferri muriat. to answer
well. In menorrhagia as in other instances a primary deficiency of
tone or power produces results which react on and intensify the
original defect.

CHAPTER XXXIV.

CUTANEOUS NEUROSES.

As the principal sensory surface the skin may be expected to
come in for its full share of nerve disorder, and this is to a great
extent actually the case. . I do not intend to refer here to neuralgic

CUTANEOUS NEUROSES. 275

pain which has been noticed elsewhere, nor to painful affections of
traumatic origin, of which Romberg cites several interesting cases.
The conditions I propose to illustrate are {a) that of increased, (b)
that of diminished sensibility, (c) that of vaso-motor nerve paresis,
(d) that of vaso-motor spasm. One or more of these may coexist.

Cutaneous hyperaesthesia is far from being uncommon as a primary
affection ; it is often associated with more or less of papular eruption,
but certainly may be quite independent. The following cases prove
this : —

No. 155.' — J. A., get. 35, m,, ad. Sept. 29th. Ill six weeks, complains
of continual itching all the whole day affecting every part except the hands
and feet — "can't bear himself when in bed." There is no eruption what-
ever. His health is good. B. open. P. weak. Feels weak. Has very
frequent calls to urinate, but passes very little. He was treated with aconite
lotion and carbonate of iron, and quite lost his itching in about three weeks.

No. 156. — Gr., ast. 47, complains of having suffered during three weeks
great irritation of the skin ; she felt as if she could tear her back to pieces at
night. At that time after scratching she says pimples come out attended
with great sense of burning and scalding. There was no eruption whatever
to be seen on the parts. With the aid of aconite lotion and acid, sulph. dil.
ni^xxx ter die she recovered from her troublesome disorder.

In other cases there is some scanty and limited lichenous eruption,
but it is evidently insufficient to account for the wide-spread and
severe itching. I believe further that Romberg's view is correct,
that even in marked cases of lichen and prurigo the hyper- or dys-
sesthesia is the cause and not the consequence of the eruption, and
this for the following reasons : —

(1) Decided inflammation of the skin produced by irritants, or as
occurring in erysipelas, is not attended with anything like the severe
itching of lichen or prurigo, yet in such cases the papillary structure
must be involved. (2) The very marked influence of warmth and
of the night in aggravating these eruptions is quite accordant with
the genius of nerve disorder, and, on the contrary, unlike that of
true inflammation. (3) One form — lichen tropicus — is produced by
conditions eminently exciting, and yet exhaustive of, nervous power.
(4) The relation of these eruptions to urticaria, which is evidently
a neurosis. (5) The very small amount of inflammation in many
severely itching eruptions. The causes of cutaneous hyperaesthesia
are generally very obscure ; it is rare that we are able to influence
the disorder by our knowledge of them. In the allied affection
urticaria it is notorious that all sorts of things will give rise to the
eruption in predisposed persons, each being especially sensitive to
some particular substance. Here the predisposition is evidently the
"grandleiden," and in hypersesthesia it is much more so, as we are
much less able to detect any exciting causes. The warmth of bed,
or of any source of heat is the chief excitor. This renders the dis-
order often a grievous infliction by destroying the patient's rest. In
he case of lichen tropicus, the "prickly heat" the elevated temper-

276 CUTANEOUS NEUROSES.

ature is no doubt the chief or sole cause, acting on nervous tissue
as it so commonly does in the way of enfeebling power and increas-
ing excitability. I have several times observed the reproduction of
lichen urticatus in my own patients by summer heat. This influence
of heat seems to me a very significant fact with regard to the essen-
tial nature of the disorder. Heat is an imponderable, and cannot
act as a "materies morbi," nor is it likely to cause the retention in
the system of " excernenda," but rather the reverse. It does how-
ever affect the nervous power very speedily and decidedly, and thus
•we can hardly avoid recognizing the disorders which it produces as
purely dynamic, and not dependent on any morbid state of the blood.
This view is supported by the fact that in two toxic disorders, gout
and syphilis, itching is by no means a marked or frequent symptom.
I do not remember to have observed it in any of the cases of chronic
gout I have had under my care; and in syphilis the less itching
quality of the eruption is notorious. Jaundice is certainly sometimes
attended with much itching, but much more often is not, at least in
my own experience. I am therefore inclined to regard the affection
we are considering as an essential neurosis, but as one which, like
many others, may differ much in quality in various instances. In
some it may be of a more sthenic, in others of a more asthenic
character. In lichenous and pruriginous disorder if at all severe
the administration of hyd. bichlorid. or some mild mercurial is requi-
site. In other cases saline aperients with a little vin. colch. may
be sufficient. Soda baths and the sulphur-fume bath are often very
serviceable; the latter, however, should not be used in eases of a
sthenic character, at least until after due depletion has been employed.
In asthenic cases tannin may be of efficacy, or arsenic. Where the
hypergesthesia exists alone, or with but a little eruption, acid, sulph.
dil. in 5ss doses ter die, or citric acid in gr. x — xv doses with
spt. oeth. chlor. are beneficial. Bismuth ointment and aconite lotion
are useful local applications. Henbane should be given in suffi-
ciently large doses (gr, x — xv of the extract) to soothe the irrita-
bility of the system, and to procure sleep at night.

Urticaria by its fugitive character, by its manifold and various
causation, by its nocturnal invasion, by the dyssesthesia attending
it, and by the nature of its phenomena fully asserts its title to be
regarded as a neurosis. Its characteristic pale wheal-like elevations
are the result of a cutaneous spasm, contracting the tissue into knots
or "bumps." In persons with highly irritable skins pressure with
a hard point on the surface will produce the same effect. Patients
complain sometimes that tl^e bumps are produced when they scratch
themselves to relieve the previously existing irritation. It is, I
think, probable that the dysEesthesia and the cutaneous contraction
are co-results of the same nerve disorder, and that the latter is not
merely a reflex of the former. ' The spasm is certainly not depen-
dent upon hyperEemia, as in urt. evanida it occurs without any.
The diffuse inflammatory redness of the skin, which is so marked

CUTANEOUS NEUROSES. 277

in some instances, and attended even with swelling, must be con-
sidered as an indication of vaso-motor nerve paresis, and we thus
get in this curious malady three different pathological changes result-
ing from the operation of the same cause, viz., spasm of contractile
tissue in certain parts, paralysis in others, and a state of hyper- and
dysoesthesia of sensory nerves. It is very instructive to note these
various phenomena developed under our eyes, intimating to us what
may occur on internal and concealed surfaces. Like most neuroses,
urticaria may be produced by remote irritation, which is in many
cases seated in the intestines, but may be elsewhere, as in the female
sexual organs. Scanzoni has recorded' some highly interesting cases
where urticaria was produced by the application of leeches to the
uterus. In one of these, a woman, set. 28, had five leeches applied
to the cervix. Scarcely had they taken hold when she complained
of most violent labour-like pains in the abdomen, and although these
soon moderated in force, they were accompanied with such intense
febrile action that the entire body glowed with heat, the pulse rose
to 140, the carotids pulsated visibly, and the face, neck, and chest
exhibited an intensely red colour, to which were added in a very
short time a large eruption of urticaria elevations of a palish colour.
The eruption was accompanied by great headache, inclination to
vomit, and excessive lassitude, symptoms which continued to the
following day, although the exanthem with the accompanying fever
disappeared entirely after three hours' continuance. Scanzoni refers
the phenomena to irritation of the uterine nerves, and states that
they could not depend on the absorption of any poison from the
leeches, as no such symptoms are ever occasioned by the application
of leeches to other regions of the body. In a third case it is stated
that the leeches had been applied eight times, and it was only on
the ninth occasion that the urticarious phenomena occurred. It is
clear how strongly the above history corroborates the theory of in-
hibitory action. Paralysis of vaso-motor nerves gave rise to the
carotid pulsation, to the cutaneous hypergemia, and through the
vagi and the coronary plexuses, as well as the fevered blood, to in-
creased action of the heart. The urticarious elevations show how a
spasm maybe produced together with a paralysis, as we have before
observed. Imponderable miasms, as that of ague, may cause urti-
caria. Probably there are several which may produce the same
effect. In some persons even of good health urticaria persists in a
chronic recurring form for years, just as many other neuroses do.
Its rational treatment consists in the removal of any ascertainable
cause of irritation, and in the administration of such means as may
seem appropriate to calm the nervous disorder existing in the par-
ticular instance. In "urticaria ab ingestis" an emetic should be
given, and followed if necessary by an aperient with or without a
dose of calomel. In the more acute febrile conditions salines with

» F. "Edin. Med. Journ.," Oct. 1860.

278 CUTANEOUS NEUKOSES.

hydrocyanic acid may be employed and subsequently mineral acids.
Cazenave recommends alkaline baths. During the presence of acute
disorder lead lotion may be; freely applied to allay the itching.
Henbane and camphor taken at night in full doses will be often
serviceable in procuring sleep. In chronic cases without evident
cause cold douching in the morning, and carbonate of iron ter die,
or arsenic, or some nervine tonic should be steadily administered.
When the disorder is produced by malaria it yields to quinine.

Anaesthesia of the skin not dependent on organic disease of
nervous structure is by no means rare in connection with neuralgia
and diphtheria, but I am little acquainted with it from my own ex-
perience in other morbid states. Tactile sensation which judges of
temperature and locality must be distinguished according to Jaksch
from common sensation, of which pain is a modification.^ The
faculty of touch may remain quite unimpaired while the consciousness
of pain is lost. Carpenter states, however,^ that the ordinary sense
of tact may remain while yet there is no power to judge of tem-
perature, and vice versa. Romberg^ says " that insensibility to pain
with a continuance of the sense of touch occurs in various diseases,
but most frequently in lead poisoning, and not rarely in hysteria,
but never in cases where the sense of touch is destroyed." It seems
difficult to reconcile the statements of Jaksch and Carpenter. For
my own part, I think it very doubtful that there are different fibres
for the conveyance of. the different sensations to the sensoriura, as
if this were the case the total number of cutaneous nerves would
have to be extremely great. It seems quite possible that a nerve
may be insusceptible of a particular impression just as the retina
in certain persons is to particular colours. Romberg mentions the
occurrence of cutaneous anaesthesia in washerwomen, and has no
doubt that the immersion of the hands in the soapy water was the
cause. The symptoms were much like those of neuralgia. Yoisin^
describes hysterical anaesthesia as by no means a constant occurrence
in all cases, as Gendrin states it to be. On the contrary, it very
rarely occurs except after severe convulsive attacks attended with
unconsciousness. Briquet however controverts this, and states that
of 221 anaesthetic females only 160 had had convulsive attacks. It
is often of short duration, lasting only some minutes or hours after
the paroxysm; but in inveterate cases it may persist for years.
Yoisin believes the anaesthesia to be dependent on the uncon-
sciousness. The left side as a rule is the one which is anaesthetic,
but sometimes the disorder affects the outer side of all the limbs, or
even extends over the whole surface. While the skin is anaesthetic
the muscles are usually in the opposite state.

Beau and Voisin agree that analgesia (loss of the feeling of pain)

' Schmidt's " Jahrb." vol. cxx. p. 43.

2 " Physiology," p. 255, 2d edit.

a " Syd. Soc. Translat.," vol. i. p. 200.

4 "Gaz. Hebdom." xlviii., 1858; Canst. "Jahresb.," 1860, vol. iii. p. 98.

m

CUTANEOUS NEUROSES. 279

is alway tlie first phenomenon in hysterical anaesthesia, that it
always precedes the loss of the sense of touch. The analgesia is at
first incomplete and gradually increases. It is rarely limited to
small spots, usually it occupies a whole side, and that the left.
When the analgesia is complete faradization with the wire-hrush
reddens the skin, but causes no pain. The mucous membranes of
the nose, the mouth, and the vagina are sometimes affected and
usually on the left side. Loss of the sense of touch Voisin regards
as a higher grade of angesthesia; it is mostly left-sided, and in rare
instances extends over the whole surface. Nearly the same may
be said of the loss of the faculty of distinguishing temperature.

Diminution or loss of the sense of resistance depends on a defi-
ciency of the muscular sensibility, and of the cutaneous tactile
faculty ; it is therefore a complex morbid state, and of rare occur-
rence, inasmuch as the muscular sense is only impaired in the worst
cases of hysteria. When this complex paralysis is complete, patients
have no perception of the size, form, weight, and temperature of
bodies placed in their hands as long as their eyes are averted.

Jaksch (v. loc. cit.) has specially studied the subject of cutaneous
anodynia. He observed it in six or eight among 120 to 130 patients
at Prague. It coexisted with other nerve disorders, especially those
belonging to the hysterical class. When extensive it may involve
all the mucous surfaces continuous with the skin. Occasionally it
happens that the tongue alone is affected, the cutaneous sensibility
remaining normal. The conjunctivae and the nasal mucous mem-
brane may be insensible to the strongest stimulants, as liq. ammonise
and mustard oil, no lachrymation or sneezing being produced. Smell
is usually lost in anodynia of the nose, and taste in that of the tongue.
Sir Chas. Bell relates a case of plethoric hysteria communicated by
Mr. Crampton, of Dublin, in which the right eye, the lids, and the
skin of the cheek and forehead about an inch around were quite
anaesthetic. The sight of this eye also had been quite lost for four
or five months, and had been dim for four years or more since a
blow on the eye. Under depletory treatment she quite regained
the sight of the eye. The anaesthesia ceased some time previously
when pain and deafness recurred in the right ear, where they had
existed before the anaesthesia. The anodynia may be general, or
one-sided, observing accurately the median line, or it may affect
separate tracts of various size. It never corresponds to the dis-
tribution of a single cutaneous nerve. The subjacent muscles are
often similarly affected, at other times not, or they may be anodynic
(to the electric current) while the skin covering them is normal. It
is very worthy of observation that the most severe neuralgia may
coexist in the same part along with cutaneous anodynia. Four-fifths
of the patients were females, the disorder prevailed most from the
16th to the 30th year of life, in uneducated persons, and more among
Jews than among other persuasions. A mental perturbation was
the most frequent cause, and healthful mental stimuli were among

280 CUTANEOUS NEUROSES.

the most eflScIent restorative means. Other useful remedies were
such as are usually employed in other neuroses, zinc, musk, quinine,
morphia, electricity, warm baths, as those of Teplitz. Cold affusions
and counter-irritation were most effectual in recent cases.

Hysterical hypersesthesia is so much more commonly observed
with us than ansesthesia, the latter perhaps being overlooked, and
the tendency in many patients of this kind to " embroider" is so
great that I confess I have for a long time received the accounts I
have read of the above condition cum grano salis, as it is not easy
to be well assured that some of the symptoms might not be feigned.
But with regard to anodynia there can be no doubt that it must be
the result of a real alteration in the state of the nerves, and no pre-
tence. No normal conjunctiva or Schneiderian membrane would
stand the test of liq. ammonias or mustard without giving unmis-
takable evidence of sensibility. The experiment is precise enough,
and unless we question the veracity of the author we must admit
the occurrence of this remarkable sensory paralysis ; and if of this
then I think of other forms of so-called hysterical disorder, as real
nerve — and not merely nervous affections. There has hitherto been
far too much confusion between the bodily and the mental derange-
ment, and because in many cases the latter has been present it has
been too much taken for granted that it existed in all, and that the
bodily was mythical. We shall always have much need to be on
our guard against deception in the case of our meeting with a
genuine hysteric, but on the other hand we have evidence enough I
think that causes of exhaustion of nerve power may generate all
kinds of morbid phenomena from the greatest hypersesthesia, muscular
agitation, and convulsion to anaesthesia, analgesia, and paralysis.
Let us only think what must be the depressing effects of constant
monotonous toil, scanty pay, poor food, bad air, and failing strength,
especially where there is no bright ray of future happiness in a
better state to light the gloom, and where in the absence of healthful
recreation gin and prostitution are the devil's substitutes, and then
say if we can be surprised at any amount of physical nervous de-
rangement. Dr. G. Bird, speaking of paraplegia the result of ener-
vation occurring in sempstresses says : "They are unable to procure
proper food, and are oftfen driven to intemperance to forget their
miseries, or to prostitution to add to their wretched income." In
awe and sadness we ask ourselves at times, " How can these things
be?"

There are a good many instances, some I have alluded to already,
of paresis affecting the vaso- motor nerves of the skin and its glands.
The profuse sweating which affects persons whose nervous power is
low depends evidently on this condition. A friend who has hemi-
plegia too probable of organic origin tells me that when he has a
lamp-bath he perspires very much more on the palsied side than on
the other. Per contra^ I have been informed that a dose of arsenic
taken before a Turkish bath will prevent perspiration being induced.

CUTANEOUS NEUROSES. 281

Sir R. Martin has related to me the case of a lady who had suffered
from frontal neuralgia and malarious fever, in whom there appeared
now and then a largish patch of redness on the forearm near the
wrist from which such an abundant perspiration flowed that several
handkerchiefs were saturated in about half an hour. If arsenic be
allowed to be a nerve-tonic, which can hardly be denied, its re-
markable efficacy in asthenic eczema, impetigo, and pemphigus must
be considered tolerably good proof that one chief constituent of these
eruptions is a state of vaso-motor nerve paresis. Not only is the
discharge arrested, but the abnormal temperature and vascularity
are reduced. This is surely very like what occurs on galvanizing a
divided sympathetic. Occasionally subcutaneous effusion occurs in
place of surface discharge, and yields to the same toning treatment.
I have recorded the case of a child, tet. 14 months, who suffered
with diffuse erythematous redness appearing in various parts, on
which at first a few bullae were developed. A few days later both
hands were intensely cedematous, the swelling had been preceded
by redness. Quinine + iron + arsenic cured, although there was
much feverishness. Certain roseolas, and erythemata, and cases of
recurring erysipelas seem to depend chiefly on want of tone in the
cutaneous vaso-motor nerves. Pemphigus hasmorrhagicus in which
the bullae contain bloody serum, of which I observed some years ago
an instance in a thin, feeble-looking man, aet. 60, forms a transition
to purpura. In the case alluded to the eruption quite ceased under
the administration at first of bark and ammonia and subsequently
of arsenic. The weakness and fragility of the capillaries, which is
the essential condition in purpura and the allied disorder scurvy,
seems to be sometimes to a great extent of neurotic origin, and at
any rate is often considerably amended by the administration of
iron and quinine. One of the severest cases of purpura I ever saw
was cured by infusion of matico, i. e., by tannin. It is often, how-
ever, necessary to premise cholagogue purgatives.

M. Parrot^ relates the case of a female, a hystero-epileptic, in
whom bloody sweating occurred during many years on the knees,
thighs, chest, lower eyelids, hands, and face. The tears were once
also tinged with blood, and there was frequently some h^matemesis.
On one occasion together with the haematemesis there was severe
epigastric pain, and the skin of this part was covered with a bloody
dew. These hemorrhages were never an isolated phenomenon ; they
always succeeded to a mental emotion, and complicated a nervous
attack attended with absolute loss of motor and sensory power. An
one time neuralgic paroxysms were attended with sanguineous exu-
dation at the painful parts. There was no deception; Parrot himself
witnessed the phenomenon. There was never any reddening of the
skin in the parts where the hemorrhage occurred. The catamenia
seem to have been pretty regular, and their appearance always re-

' "Gaz. Hebdom.," 1859, 40—17,

282 CUTANEOUS NEUROSES.

lieved the cutaneous hemorrhage. Parrot cites various other re-
corded cases of a similar character, and observes, in conclusion, that
this cutaneous hemorrhage may coexist with others of a similar
character in persons of a delicate, irritable constitution, especially
in females; that all these hemorrhages not only are associated with
general nervous perturbation, but are further frequently connected
with localized phenomena of pain and spasm; that they closely re-
semble these phenomena with regard to their efficient causes, the
parts which they affect, the suddenness of their invasion and cessa-
tion, and their harmlessness. These hemorrhages, which he terms
neuropathic, proceed he believes from the glands of the external and
internal tegument. They consist of true blood, and not merely of
red-stained serum.

Under the head of spasm of the vaso-motor nerves of the skin I
might allude to the common "dying," as it is called, of the hands;
when under exposure to cold the fingers turn white and numb, so as
to be often for the time almost useless. Sir B. Brodie, in his work
on Local Nervous Affections, p. 42, observes that in some of those
who are subject to so-called hysterical disease of the joints the whole
limb is affected with a remarkable alternation of heat and cold.
Thus in the morning the limb may be cold and of a pale or purple
colour, as if there were scarcely any circulation of blood in it, while
towards the afternoon it becomes warm, and in the evening is actually
hot to the touch with the vessels turgid and the skin shining.
Graves mentions a remarkable case of somewhat the same kind, the
patient being a young female. One leg and foot at a time became
very hot, swollen, smooth, shining, and as dark in colour as a ripe
black cherry. When the hot fit ceased, the slight swelling and the
discoloration subsided, and the affected parts remained during the
next stage pale, deadly cold, and comparatively free from pain.
Only about three hours of complete intermission ensued in the
twenty-four, one leg becoming affected as the other recovered. It
is remarkable that perspiration does not seem to have occurred in
consequence of the hyperemia. In these cases we have examples
of alternating spasm and paresis of the cutaneous vessels; in the fol-
lowing I think the phenomena are mainly due to spasm.

No. 157. — A girl, set. 17, without known cause felt violent pain in the
hands ; four fingers of the right and two of the left became slate-coloured,
cold, insensible — in short, exhibited all the symptoms of incipient gangrene.
Movement was almost entirely abolished in these fingers. The induced
current was applied, giving rise at first to increased pain, but soon arresting
the suff'erings of the patient. After ten to twelve sittings at about the end
of a week the sensibility, the normal temperature, and colour, as well as
motion, were restored. The epidermis came ofi" to the extent of the first ap-
pearance of the gangrene. During electrization a fetid sweat was noticed
over the electrified parts. — (v. Brit, and For. Med. CMr. ReV', April, 1859.)

No. 158. — W. P., set. 32, indoor servant, seen May 6th, 1856, ad. into
hospital fourteen days ago. Has had no particular disease during his life ;

CUTANEOUS NEUROSES. 283

Lealtli good when his fingers became affected and for some time after.
States that from two to three weeks before he was admitted his finger-tips
were quite black and cold, but not numb ; every one thought they were
going to mortify. Before they turned black they used to be cold and numb.
This state lasted about six weeks, the numbness then went away, and they
became exceedingly tender and burning. During this second period, if he
had his fingers in bed they were burning, if he left them out they got very
cold. Between the two dys^esthesiae he was prevented from sleeping.
During the first period when the fingers were cold and numb they used to
swell much at night. Some of the fingers now are perceptibly colder than
the others, and of a semi-livid tint, and the cuticle yields under pressure
with a sense of crackling, the pressure causing much pain though the part
is numb. In other fingers that are recovering the cuticle is detached, and
the skin is rather swollen and of a brightish red; and nearly normal warmth,
and sensibility. The left ring-finger has quite escaped, and the right little
finger. June 3d. Is exceedingly weak, pulse very weak. Right middle
finger turns quite white when exposed to cold, while the other fingers of the
same hand at the same time turn black and blue. All the fingers are now
red and warm, the weather being so. Eight index and mid-finger are very
thinly covered with epidermis and are very tender. Left fingers are all
quite well. Says his fingers have not gone on nearly so well since he left
off the pot. iod. + quinine which he took for the first nineteen days. Since
then he has had calomel + opium bis die for an attack of epidydimitis. By
July 5th he was pretty well recovered, and left the hospital.

Mr. Myrtle records^ the following case, which he terms one of
angemic sphacelus.

No. 159. — A military man, strongly built, and of sanguine temperament,
aet. 46, healthy-looking, and having enjoyed uniform good health in spite of
seven years' active service in the tropics and in the Crimea, complained of
the following disorder. The fingers of both hands, especially those of the
right, were pale and cold ; the right little finger from its point to its middle
felt cold as ice, and its ungual phalanx was blue — looked as if dead ; under
the top of each nail, and extending across, there was a purple line about one-
tenth of an inch in breadth. The thumbs and the rest of both hands were
natural. The last phalanx only of the right little finger was devoid of
sensation. The ears were much colder than natural, had a mottled appear-
ance, and exhibited on the outer and posterior part of each helix a number
of ecchymosed patches. Heart's action normal but weak. Five days later
he passed a sleepless night, having been kept awake by severe and constant
burning pain in the feet and toes ; the feet were pale, cold, and clammy,
the extremities of the toes being bluish and tender to the touch ; the fingers
except the little one were well, and the ears nearly so. The extremity of
the right little finger became gangrenous and was removed by Mr. Walter
Coulson, who was satisfied by careful examination that there was no disease
in the arteries. Myrtle is of the same opinion, and refers the symptoms to
feeble action of the heart, and lowered vitality from deficiency of nerve-force.
Citrate of iron and quinine seem to have been most beneficial as a remedy.

Remarks. — In these three instances the malady seems to me to have
consisted essentially in disordered innervation. The coldness and numbness

*'L%ncet," May 30th, 1863.

281 CUTANEOUS NEUROSES.

were no doubt the result of spasmodic contraction of the arteries, which
produced in the two first cases the death and detachment of the cuticle from
arrest of nutrition in the lowermost layer of cells ; and in the second actual
gangrene of a part of one finger. The lividity of the parts whose supply of
blood was arrested depended on the stagnation of venous blood in the capil-
laries; it may be easily produced by application of ice to the surface, and
removed again by warmth, v. p. 30. Why the cessation of vis a tergo
should cause this remarkable venous congestion is not quite clear, especially
as it is not an invariable result. The constringent influence of cold some-
times makes a part quite pale and white, as it did the right middle finger in
the second case, while the adjacent ones were livid. When this occurs we
must suppose the capillaries and veins to have become emptied, perhaps by
contracting like the arteries. I say perhaps, for I have seen whole tracts
of capillaries in the frog's web appear empty and void of blood-corpuscles
when their arteries were contracted, while they themselves were perfectly
patent. It is probable that an alteration of the normal attraction and re-
pulsion between the corpuscles and the tissues is concerned in the phe-
nomenon. The exemption of one finger of each hand in the second case is
a curious circumstance, and may be cited as a proof that the disorder could
not depend on any external influence. The dependence of the disorder in
the third case on some general "motor" must be admitted from the ears and
the feet becoming aff'ected in a like way. That "motor" may have been
latent malarious infection in the one instance, but in the others there was
no history of any exposure to such morbific agency. It is very remarkable
that in the cases of brachial neuralgia I have seen there has never been
any modification of nutrition of the suff'ering parts. I know not how to
account for this except by supposing that the vaso-motor nerves were
unaffected. If this be the true explanation, it is curious that the morbific
cause should be so limited in its operation as to act on one set of nerves
forming far the larger part of the nervous supply and to leave others close
by intact. The peripheral character of the disorder was very evident in all
the instances. Embolism may I think be quite excluded as a cause. These
cases are suggestive as to the possible occurrence of gangrene or wasting in
internal parts, from similar ansemiating arterial spasm. The treatment of
such cases should consist I think in the administration of iron and quinine,
ol. morrh., and belladonna in full doses, in the application of warmth and
mild local stimulation, and the continuous electric current, though the in-
duced proved beneficial in the first. This result was produced I think by
the stimulus exhausting the undue excitability of the nerves.

It may admit of some question how far the alterations which
ensued in the two preceding cases resulted directly from deficient
nervous influence. It seems quite certain that mere loss of sensa-
tion in a part from division of its nerve causes of necessity no de-
rangement of nutrition in it. The various branches of the fifth have
been divided repeatedly without any such result both in man for the
relief of neuralgia, and in experiments upon animals. The glosso-
pharyngeal has also been divided and the gustatory without the
nutrition of the tongue being notably affected. Romberg (vol. i. p.
20, 22) cites two cases in which it is mentioned that the digital
nerve on one side of a finger was divided, but nothing is said of any
other result than the relief of pain. BUttner, after dividing the

CUTANEOUS NEUROSES. 285

fifth nerve, protected the eye by a watch-glass, and found that so
long as it was thus kept from external irritation not the least alter-
ation occurred. Jobert de Lamballe divided the sciatic nerve for
the relief of severe neuralgia and spasm of the muscles, and about
three weeks after the crural nerve on account of the persistence of
pain in the thigh. The patient was delivered from his pain, but
got an eschar on the sacrum and subsequent pyaemia, of which he
died. No ulceration seems to have occurred in the limb itself, and
the sloughing of the sacrum of course could not be the result of the
operation. (V. Union Med.^ No. 77, 1859.) Malagodi seems to
have performed the same operation with a successful issue. Mr.
Paget gives two cases from his own experience proving that nutritive
repair may take place perfectly in paralyzed parts. On the other
hand, there are cases which show that when nerves have been injured
by disease or violence the circulation and nutrition of the parts sup-
plied by them may be much impaired. Mr. Simon mentions {Led.
on Patliology, p. 74) the case of a man who some months previously
had torn his ulnar nerve at the inner condyle ; his two inner fingers
had become swollen and livid with vascular injection. A female [v.
loc. eund.) had disease of a large portion of the sciatic and lumbar
plexus of nerves on one side, causing palsy and ansesthesia of the
limb ; neuralgia was referred especially to the vicinity of the knee,
and at this spot ulceration had occurred. Sir B. Brodie records
two cases of division of the ulnar nerve by accident in which three
months, or some years after the occurrence, the little finger was
numb, cold, of a purplish colour, and in one presented vesications
followed by superficial sores which healed, but recurred again.
Mr, Paget cites cases from Messrs. Travers and De Morgan, showing
that the reparative process in the same person after injuries to the
cord goes on well in the sound, but scarcely at all in the paralyzed
parts {Led. on Pathol., vol. i. p. 43). Mr. Hutchinson and Mr.
Lyle have recorded cases of paralysis of the ulnar and median nerves
from wounds in which the hands were livid and from 4° to 6° F.
colder than the corresponding healthy. (V. Med. Times and G-az..,
1863, Feb. 14th, March 21st.)

The notorious liability of palsied parts to be injuriously afi"ected
by degrees of cold or heat which a sound part could well endure,
and the great tendency of the eye to sufi'er from destructive in-
flammation when the fifth nerve is divided, make it nearly certain
that loss of nervous influence does in some way impair, though it
does not abolish, the nutritive power of the tissues. The paralyzed
parts are more liable to disease than sound parts, but do not neces-
sarily suffer. Further it appears that irritation of nerves may be a
more potent cause of disease than even paralysis. Mr. Hilton's
case proves that irritating pressure on a nerve may determine ulcer-
ation in the parts supplied by it (v. Paget' s Led', on Path., vol. i.
p. 43). In a case recorded by Mr. Hooker (v. Lancet, Oct. 1st,
1859) where the popliteal nerve was successfully divided on account

286 OSTEAL NEURALGIA.

of obstinate neuralgia of the leg attended with ulceration the ulcers
healed soon after the operation.

It is very conceivable that where a nerve is injured by violence
the cicatrix may keep up irritating pressure on accompanying vaso-
motor nerves, and so the bloodvessels of the parts supplied may be
persistently contracted, and the nutrition of the tissue suJOfer in con-
sequence. This will be all the more likely to happen if the vital
power of the part is eiflier originally weak, or is impaired by loss
of its normal vis nervosa.

Osteal Neuralgia.

Authors scarcely seem to recognize the occurrence of neuralgia ^
in bone; I find no mention of it in Romberg, Erichsen, or Copland. I
The following is I believe an instance.

No. 160. — W. S., m., set. 52, ad. Dec. 7th, ill fourteen days. Is a strong-
looking man, but has led a dissipated life ; denies having had syphilis, but
allows gonorrhoea. Never had gout, nor had his parents. He complained
of a lichenoid eruption all over him, itching much when he was warm, and
of great tenderness of the external condyle of the right humerus; this part
feels just as if it was bruised, but there is no sign of any injury and no
thickening to be felt. The disorder came on gradually. The pain caused
considerable impairment of the power of the elevator muscles of the right
arm; he could not raise any weight, nor take down his coat from a peg, nor
put it on. Health perfect. A blister over the condyle, pot. iod. gr. x ter
die, quinine and strychnia with ol. morrh. were of no benefit, but three sub-
cutaneous injections of liq. opii sedat., and the inunction of veratria over
the painful condyle almost removed the neuralgia by April 7th. It was re-
markable that the accidental application of veratria ointment to his legs
caused extreme tinghng, while the skin of the condyle was affected very
much less. As the neuralgia declined, the arm regained strength. The
itching was out of all proportion to the amount of eruption visible by day ;
it was greatly amended by citric acid gr. xv + spt. seth. chlor. rti x ter die,

A young lady is at present under my care with an evidently
similar affection of the lower dorsal and lumbar spines; the tenderness,
however, extends also some little distance on either side. In this
situation neuralgia is by no means uncommon, and I quite agree
with Romberg in believing that the phenomena ascribed to spinal
irritation are nothing more than ordinary hysterical and neuralgic
disorder. Certainly I can see no ground for supposing that con-
gestion of the spinal cord or its membranes forms any part of the
morbid process.

MALARIOID DISORDER. 287

CHAPTER XXXV.

MALARIOID DISORDER.

Perverted and distorted as the truth respecting malarious disease
has been by certain Avriters, so that a sober-minded man feels almost
necessarily fearful of being thought to sanction in any degree their
extravagances, it yet remains unquestionably true that there is no
group of morbid affections of more weighty and practical interest,
and which more claim our attention, than those which belong to this
class. I will refer briefly to some of the points which justify this
statement. (1) The almost universal prevalence of these diseases
in all parts of the world is a striking fact. One can scarce open a
book of travels without lighting on some reference to the endemic
fever. Most intense and wide-spread in the tropics, where the mala-
rious influence sets its stamp on almost all morbid action, it prevails
as far north as 62°. (2) The apparent absence of anything special
or peculiar in the conditions which give rise to it. Moisture and
warmth seem to be the efficient causes of this strange malignant in-
fluence. A soil, or even a rock needs but to have been wet and to
undergo drying to become a source of disease. Even drying wood
is adequate to produce the miasm. I am aware that evidence has
been collected to show that ferruginous soils are eminently prone to
generate malaria, but it cannot, I think, be contended that this fatal
quality is peculiar to this kind, or to any. Rather it seems like the
fulfilment of the original curse pronounced on the ground for man's
sake. Excess of moisture and complete dryness arrest the develop-
ment of malaria, indicating plainly that the formation of the poison
is somehow connected with the act of drying. (3) The obscure (but
undoubted) relation between malarious disease, influenza, and cholera,
and the much greater prevalence of these disorders in some years
than in others. (4) The very various diseases which malaria com-
monly produces, as fever, neuralgia, and dysentery. These may
stand as representatives of the chief kinds of morbid action, showing
how multiform may be the phenomena which spring from this origin.

(5) The especial predilection of malaria for the nervous system, and
the vast, almost endless variety of disorders it is capable of gene-
rating through the intermedium of this system. This circumstance,
and the consequent tendency of ague to be associated with peculiar,
anomalous, and alarming symptoms, as in the so-called pernicious
fevers, give a deep interest to the study of malarious afi'ections.

(6) Though in our own land we see comparatively little of malarious
disease in its more severe forms, yet owing to the wide extent of our

288 MALARIOID DISORDER.

colonial empire there are but few families who have not some mem-
ber more or less exposed to suffer from them, and the number of
those who return home invalided from such disease is large and in-
creasing. It is quite clear, therefore, that a practitioner should be
•well acquainted with the manifold manifestations of malarious intoxi-
cation if he desire to meet the requirements of his day. It is by
no means sufficient to know how to manage a tractable, well-behaved
ague ; we should be prepared for a variety of strange, anomalous,
and puzzling forms of disorder which will be sure to perplex us if we
have no clue to guide us to comprehend them. This clue will be
found (1) in a knowledge of the laws of neuropathology as developed
by Bernard and others; (2) in an acquaintance with the action of
malarious influence on nervous tissue. The former topic has been
sufficiently noticed. With regard to the second, it may be remarked
that the phenomena from which we have to judge do not all present
the same character. The contracted vessels, and skin, and the rigors
of the cold stage of ague appear to evidence a stimulation of vaso-
and musculo-motor nerves; while the increased temperature, the full
pulse, the flushed surface, and the dilated vessels of the hot stage
all show the existence of a state of paralysis of nervous and mus-
cular tissues. The diarrhoea, dysentery, splenic, hepatic, or thy-
roidal enlargement which are so frequently produced by malaria,
can only be interpreted as results of dilated and paralyzed arteries,
and consequent excessive flow of blood to an enfeebled tissue. In
some cases paralysis of some of the voluntary muscles has resulted
from exposure to malaria. The state of a nerve in neuralgia, as I
have endeavoured to show, is much more akin to paralysis than to
excitement, and is commonly attended with more or less paralysis of
the motor fibres contained in a compound trunk. The general con-
clusion from these facts clearly is that the action of malaria is
mainly paralyzing, though its earlier operation may sometimes
appear to be stimulating. I say appear, for I am very much dis-
posed to think that the stimulation is only apparent, and this for
two reasons : First, the voluntary power is certainly weakened, and
the quasi-spasmodic contractions may proceed much like those of
chorea from a state of undue mobility and excitability of the nervous
centres. Secondly, there is certainly, as I can testify from personal
experience, a remarkable hypersesthesia of the cutaneous nerves,
which are far more sensitive to cold than in the healthy state. This
hypersesthesia as well as the motor disorder may result from paresis
of the centres according to the general law that power and excit-
ability vary inversely. It is by no means improbable that the
whole train of disorders may result from a primary vasomotor nerve
paresis giving rise to increased heat of the blood, which then might
produce at first an unhealthy irritation of the nervous centres issuing
sooner or later according to the quality of the nervous power in ex-
haustion and paralysis. It is well known that increased heat of the
blood is one of the earliest occurrences in fevers. However this be,

MALARIOID DISOKDER. 289

•whether the spasmodic phenomena result from fevered blood, or from
the direct action of the poison, there is no question that the stimu-
lation is of an unhealthy and injurious kind, and that we have in
the coexistence of the apparently differing phenomena above men-
tioned another proof of the connection existing between spasm and
paralysis. The result of the action of malaria may probably vary a
good deal according to the idiosyncrasy of the individual, and accord-
ing to the virulence of the poison itself. Just as to some persons a
moderate dose of opium proves a powerful stimulant, while in others
it causes more or less powerlessness, so it may be with malaria.
Beyond any doubt the prolonged operation of malaria has a remark-
ably enfeebling and lowering effect on nerve power both in the cerebro-
spinal and sympathetic systems. In any actual paroxysms of mala-
rious disorder we must of course be guided in our therapy by the ex-
isting circumstances. If the symptoms are such as indicate constricted
arteries and anaemic organs, we must act very differently to the way
in which we should if peril arose from active congestion of an im-
portant organ produced by the opposite state of nerves and vessels.
Two main points to remember will be (1) that loss of functional power
may result from constriction of the arteries supplying a part; (2) that
over-excitement, and even inflammatory phenomena may depend upon
an opposite condition. I have already given various instances of the
pernicious and irregular forms of malarious fever, v. Cases 4, 5, 34,
104, 105.

I would refer for other examples to M. Bailly's work on inter-
mittent fevers, and to Torti's Th^rap. Special.

I shall now proceed to notice some of the obscurer forms in which
malarious disease appears in this country, (1) in children, (2) in
adults. I do not intend to advert to common ague, or its hemi-
cranial equivalent, but to some maladies which are scarcely re-
cognized in ordinary text-books, though they have not escaped the
observation of Dr. Copland and Dr. Macculloch before him. As
my field of experience has been a district of London, it may justly
be expected that I should adduce some proof of the possible pro-
duction of malaria in this place.

Case 1. — A hard-worked medical man, resident in Paddington for eleven
years, informs me that so far as he knows he has never been in districts
where ague is prevalent. About 1853 he had distinct quotidian, and during
three years was often subject to recurrences of similar disorder.

Case 2. — G-. S., set. 30, ad. June 5, 1857, works in sewers. He was in
Kent ten months ago ; no one had ague in the place to which he went ; he
remained there fourteen days. After this he returned to Paddington, and
has been working there ever since, not near the canal. Tertian ague began
nine weeks ago; it ceased after treatment in six weeks, but ever since he
has had neuralgia of both sides of the chest at the lower parts, with sink-
ing sensation, and occasional burning heat flushes.

Case 3. — L., set. 19, residing not far from the Paddington canal, has a
decided attack of ague, never having suffered from it before, nor having re-
sided in any known malarious district.
19

290 MALARIOID DISORDER.

Case 4. — S. A., f., set. 15, ad. May 13, 1857. About fourteen days ago
Lad tertian ague for the first time. It came on without any known cause.
She came from Norfolk to London 3 there was no ague in the part of Norfolk
from which she came.

Case 5. — May 5, 1857. A policeman, aet. 25, living at Walbrook in
the city, employed on night duty, has tertian ague, the rigors occurring every
other night. He was previously a carman at Maidstone, of most abstemious
habits, had no ague before he came to London, where he had been about eleven
weeks before the disorder came on.

Case 6. — J. S., set. 33, m., ad. April 8th, ill about a month, never had
a day's illness before, never was in Kent or Lincolnshire, has been in Lon-
don eight years. Ascribes his illness to a cold. His illness began with
rheumatoid swelling and pain of hands ; in about fourteen days this subsided,
and marked quotidian ague appeared, which continued a few days, was
arrested by quinine, and after a week relapsed again.

Case 7. — C. M., set. 32, m., ad. May 16, ill three weeks with tertian
ague, which he thinks he got while working in wet in Russell Square.
Never had ague before, never was where there was ague^ has not left Lon-
don for thirteen years. Always a healthy man. Has had five paroxysms.
Is sick and vomits in the cold stage. The ague was arrested by quinine
temporarily, but he did not attend long enough for a cure to be efiected.

Case 8. — J. S., f., get. 40, April 27, 1863. Ill fourteen days with tertian
ague. Was born and lived in a Lincolnshire fen; people around her often
had ague, but she never had it; left her home at set. 14, and resided in
Cambridgeshire and Lincolnshire. Has been in London twelve years; never
had ague till now, nor any particular illness.

My friend Dr. Brinton related to me the following case which
occurred in his hospital experience. An omnibus driver who had
always been in London suffered with severe inflammation of one eye,
which had resisted all sorts of remedies for a long time, during which
he had been under another physician's care. Taking the hint that
there occurred a slight remission in the course of the day, Dr. Brin-
ton gave him full doses of quinine, which acted magically, and he was
soon well. I could easily add other examples to the foregoing, but
they seem to me sufficient to prove that London, during the last
twelve or fifteen years at any rate, has been capable of generating
an influence giving rise to well-marked ague. Case 8 proves either
that London may pioduce ague, or that it may call into activity a
latent predisposition contracted in a malarious district, and which
that locality did not render active. In either case the occurrence is
sufficiently significant. The chief value of the facts above adduced
is, in my opinion, the proof they afford that in obscure cases of
disease of the nervous system occurring among ourselves it is right
and necessary to take into account, in forming a diagnosis, the 2^0 ssible
presence and Operation of a malarious taint as the cause of the
symptoms. This is no mere hypothesis, I am convinced from ex-
perience of the soundness of the view. It ought to be remembered
that malarious disorder is very multiform, and that, especially in
London, for one case of actual ague we may have fifty of variously

MALAEIOID DISOEDER. 291

modified disorder. The following is an instance; A medical friend,
who had twice had ague, and had resided in a malarious district,
but had been for some time in London, experienced for three con-
secutive mornin2:s chills occurrins; at 11 A. M. ; on the fourth mornino;
he had instead acute neuralgia of the neck and shoulder at the same
hour ; on the fifth he had neither chills nor neuralgia, but epistaxis
at the same time ; he had not provoked it in an j way. A very
strong reason for acquainting ourselves thoroughly with the obscurer
forms of these afi'ections is, that they are not self-limiting, like our
ordinary continued fevers, but are evermore, unless arrested by
remedies, prolonging their weary course by perpetual relapses and
recrudescences. I doubt if any diseases are more wearying and dis-
tressing than those I am now alluding to.

The first I shall more particularly notice is a disorder which is by
no means uncommon in young children between the ages of 2 and 10
years, and to which I have given the name of Malarioid Remittent.
It has quite the character of a re- or intermittent fever, the parox-
ysms occurring at night, while the day is more or less free. The
illness commences gradually, and has often lasted several weeks
before the little patient is brought for medical treatment. It is
usually regarded at first as some casual derangement of the stomach
or bowels even by medical men. In well-marked cases there is
drooping, languor, fretfulness, and loss of appetite by day, while at
night the sleep is restless and disturbed, and not unfrequently there is
considerable delirium. This delirium may be the prominent, indeed
almost the only symptom, of which the following is an instance.

No. 161.— W. H. B., m., jet. 5, seen April 1st, 1859. He had been
under my care nearly two years before with considerable nightly delirium
and screaming, and with lameness of the right leg and neuralgic tenderness
of both. I was then suspicious of scrofulous hip disease, but neither I nor
one of my surgical colleagues could discover sufficient evidence that such
existed. He was then treated with quinine in 2 doses at 7 and 9 P. M., and
recovered so far that he slept well, and only halted in walking without having
any actual pain in the legs. He had now come into the hospital with mani-
fest hip disease ; an ulcer was discharging near the left. While awake in the
day he was pretty well, but if he slept, or at night during sleep, he talked
wildly and screamed so much as to disturb the other patients considerably.
When asked if he was in pain he answered no, and promised not to screani
again. My advice was asked respecting him, as it was found that he had
been an out-patient of mine some time before. I gave him at first gr. iij of
quiaine in 2 doses at 6 and 8 P. M., but after three days of this treatment
the screaming was even worse. The quinine, however, did not otTierwise
disagree, so I doubled the dose. From that time he ceased to scream, and
slept quietly during the three weeks he remained in the hospital. The dis-
charge from the hip also lessened materially, and his general state improved.
The persistent character of the disorder was very evident in this instance,
as well as the action of the remedy, which fully justified the diagnosis. The
history shows also the necessity for duly adjusting the dose of a remedy,
and not rejecting it too hastily as inefficient or even injurious, which might

292 MALARIOID DISORDER.

have been supposed to be the ease here. In very many eases some of the
organs are more prominently affected than others. Thus we may have cere-
bral, or thoracic, or abdominal symptoms, which will simulate, and some-
times very perplexingly, substantive disease of the various viscera. I shall
adduce instances of each.

No. 162.~T. M. A., ^t. 2, m., ad. Jan. 10, ill 14 days. Had two fits
first, and one last night; during the fits and at other times beats his head
as if he had pain in it, and works his occiput against the pillow. Always
screams when pain takes him in the head. From 5 P. M. to 5 A. M., is
very restless and delirious. Is dreadfully irritable even in the daytime.
Has only vomited once, and that was yesterday. No typhoid spots. Pupils
of medium size. Knits his brows. Head rather hot and skin generally.
Bowels costive. No appetite. Tongue clean. Pulse feeble and quick.
Hirud. ij, temporibus. Hyd. c. creta gr. ij h. s. Qain. disulph. gr. j ter die.
13th. Had a double dose of quinine last night, and passed a very good night ;
did not disturb his mother once. Healthy motions. Quin. disulph. gr. ij
0. n. Pt. c. gr. j his die. 17th. No fever now, head cool, has fair nights.
31st. Sleeps much better, looks very well, but has no appetite. Omitted
mist., hyd. c. cret§. gr. j alt. noct. Feb. 7th. Much better. Discharged.
It is not too much to say that there was grave reason in this case to fear the
existence of meningitis, probably tubercular. No doubt there was con-
siderable hyperasmia of the brain, but this was more from arterial dilatation
in consequence of vaso-motor nerve paralysis, than from actual inflammation
of the cerebral tissue. As the nerves were toned and the vessels contracted,
the hypersemia subsided. Had a different plan been pursued, as repeated doses
of calomel, it is highly probable that the case would have terminated
unfavourably. It is desirable to digress slightly here to call attention to
certain rheumatic affections of the head in children which resemble the
cerebral form of malarioid remittent a good deal, but require a different
remedy. I allude to pot. iod., which I have found on several occasions
very serviceable when the symptoms had a rather threatening resemblance
to acute hydrocephalus. The following is an example: —

No. 163. — C. A., m., get. 7, ad. Feb. 7th, ill five days. Complains dread-
fully of pains at back part of head. Is restless and convulsed at night,
"working with his eyes." Appears "lost in thought" at times, stupefied I
suppose. Pulse feeble. Skin cool. Bowels costive. Very weak and languid.
Quin. disulph. gr. ij ter die. 21st. Same pain, sleeps very little better. Pot.
iodid. gr. iss. Dec. cinch, ^ss ter die. Hydr. c. creta c. pulv. rhei alt. noct.
28th. Sleeps quite well, and does not complain of pain in head. Pt. mist,
c. tr. cinch. 5ss ad ^ss; ol. morrh. 3j ter die. No recurrence of symptoms
by March 17th, when he ceased attendance. An important element of
diagnosis between these and more serious diseases is the non-progressive
character of the disorder in the former ; the symptoms do not become
materially worse, though two or three weeks have elapsed since their first
appearance. In tubercular meningitis there is not the same degree of fever
at night, but more tendency to irritability of the stomach and retinae.
Trousseau indicates depression of the abdominal walls, the tache cerebrale,
paralysis most marked on one side, dilated pupils, strabismus, constipation,
extreme rapidity of the pulse, stupor interrupted occasionally by a single
loud cry, and great irregularity of breathing as the characteristic symptoms
of this almost hopeless malady. In doubtful cases it will generally be well
to act on the more favourable view, and to give either pot. iod. alone, or

MALARIOID DISORDER. 293

pot. iod. with quinine. A few doses will usually give us results which will
materially aid to determine our diagnosis. Dr. Coldstream^ speaks very
favourably of pot. iod. in substhenic inflammatory disease of the brain in
children.

The next variety I shall notice is where chest symptoms pre-
dominate.

No. 164.— E. L., f., a3t. 6, ad. Feb. 2d, ill a week. A fair, pretty child.
Has violent cough, no appetite, some days has much fever. Is very restless
and coughs badly at night. T. red and coated. P. quick and weak. Grood
breathing all through both lungs. Is worse at night and very thirsty.
Subject to these attacks every five or six weeks since her infancy. Eerri et
quin. citrat. gr. v ier die, gray powder and rhubarb twice a week. In a
week she was sleeping much better, in fourteen days the cough was almost
gone, and the appetite was very much better. By March 12th she was
well.

No. 165. — "W. D., set. 8, m., ad. Sept. 6th, having been ill on and off
since he had an attack of the same kind fifteen months ago. Blue eyes,
light hair, intelligent face, rather prominent forehead. Is very fond of
reading. Has lost much flesh. At times has a "nasty dry cough." Com-
plains of uneasiness at the lower part of the sternum. GrOod breathing in
the backs, some crepitation is heard below the right clavicle. Abdomen
normal. Skin hottish with perspiration on face. Does not sleep well at
night, rambles and talks. He varies much; one week he is all life and spirits,
the next much depressed. Hydrocyanic acid and salines fer die. 9th. Lies
sleeping very much by day, is pretty quiet at night, takes food fairly. Rales
are heard over both fronts and backs. Quin. disulph. gr. j ter die. 16th.
Seems quite well, is up and running about. Cod-liver oil was now given
with iron and quinine, and in another week he was discharged well.

In the first of these two cases there was nothing remarkable except
the cessation of the cough without the use of any sedative. In the
second the resemblance to phthisis was so considerable that I paused
a few days before I gave tonics. The physical and mental consti-
tution of the child, the emaciation, the cough, the sub-clavicular
rale with the febricitation, pointed very much in the direction of
tuberculosis. The extension of the rale all over the chest a few days
later warranted the hope that the chest affection was only catarrh,
and the result of tonic treatment soon made the case quite clear.

No. 166.— A. E. D., f., set. 2J, ad. March 10th, ill two months. Looks
seriously ill, has emaciated rapidly the last week. Has a bad cough, wheezy
perspiration, no appetite, bowels costive, skin hottish, tongue coated at back,
tip red, thirsty, likes cold drinks, lips pallid, legs cold. Very fretful, very
restless at night, but not delirious. No dulness, but moist crepitant rales
all through posterior parts of both lungs, harsh breathing in fronts. Father
died consumptive. This child, as she lay in her mother's arms, looked so
ill, and the symptoms, together with the history, pointed so much in the
direction of tuberculosis (diffused miliary), that I felt very desponding as to
the result. But there was just a hope that the disease might be malarioid

1 "Edin. Med. J.," Dec. 1859.

294 MALARIOID DISORDER.

fever with chest complication, and, as this was far the more hopeful view, I
resolved to act upon it. It was quite clear to me that it was not a case of
mere ordinary bronchitis ; the peculiar and deep prostration evidently be-
tokened either fever or some grave organic disease. Turpentine stupes
were ordered to the backs, pulv. Doveri gr. iij o. n. and quinse disulph. gr. j
quater die, dissolved by citric acid in citrate of potash saline. 17th. More
cough, but appetite much better ; has slept pretty well ; much less rale in
backs ; air enters freely. Quin. disulph. gr. xx, acid, sulph. dil. q. s., liq.
opii sedat. ttlxxx, aquae 5vj. M. §ss ter die. Pt. pulv. 24th. Much better,
much better night's rest ; cough still troublesome ; clear breathing without
rales in both backs. Pt. 01. morrh. 3j ^^r die. April 18th. Quite well.

Abdominal complications are more rare than I should have ex-
pected; they occur both as neuralgia, diarrhoeal, or dysenteric
purging.

No. 167. — E. B., f , set. 6, ad. April 7th. She had been ill one week
with a bad cough and much expectoration ; could not rest at night, and
moaned in her sleep. During the first week a cough mixture containing
chloric ether was given, gray powder and rhubarb. 14th. She complained
of very severe abdominal pain, which, however, did not seem like that of
peritonitis, and lay in bed constantly whining and crying. She was very
weak, and perspired very profusely. No thirst. B. open. Urine red and
thick. Coughs much, but there are no rales in the chest. Heart's sounds
normal. Cat. lini abdomini. Ferri etquin. citrat. gr. v, acidi hydrocy. dil.
Tt\^ij, liq. opii sed. TTLij, aq. ^ss ter die. 17th. She had ceased to complain
of pain in the abdomen, but was feverish, thirsty, and perspiring dreadfully,
and had pain in her legs. T. moist and clean. Pt. 21st. Much better,
but fearfully weak, and seemed to have lost the use of one of her knees.
28th. Much better, but still very weak ; can move her knees better. She
continued iron and quinine with ol. morrh. for another month, and made a
good recovery. About a year later she came under treatment again with
similar disorder, only that there was now chest affection instead of intestinal.
With iron and quinine and oil she again recovered well.

No. 168. — H. J., m., set. 5, ad. April 19th, ill four weeks. Skin hot.
P. rapid. Breathing harshish in both backs, without much rale. Abdomen
not very tense. B. relaxed much, motions very offensive. Emaciated
greatly, used to be very stout. Slight cough. I gave him at first gray and
Dover's powder ter die and ol. morrh. After three days the powder was
given at night only. 26th. Looks very ill, lies in his mother's arms utterly
prostrate. B. have been quieter, but are more relaxed again. No appetite.
Pt. olio. Bismuth and opium post sing, sedes liquid. May 3d. Much more
appetite. B. quiet ; motions very dark and offensive. Pt. c. mist, et oleo.
24th. B. are in much better state, but still apt to get loose ; has had marked
pyrexia, but there is less now. Sweats most copiously at night, and by day
if he sleeps. Gaining flesh. Quin. disulph. gr. xviij, acid. s. dil. q. s., liq.
opii sed. rti xxv, aq. gjss — 5j ^*'s <^^^- After this he improved decidedly,
the sweating diminished, and he was well in three weeks.

In both these cases there was exceeding prostration, which, in
the absence of sufficient organic disease to account for it, should
always direct our attention to the nervous system. In both also
there was very copious sweating, which is often, with due regard to

MALARIOID DISORDER. 295

tbe circumstances under which it occurs, a valuable indication of a
neurolytic state, and of the need of nervine tonics. The neuralgia
in the first case was as evidently dependent on debility of sensory,
as the sweating was on a like state of vaso-motor nerves. In the
second case, both the intestinal and cutaneous fluxes evidently re-
sulted from the same nerve disorder. At the time the latter case
occurred I was less familiar with malarioid remittent, or I should
have given the quinine much earlier. In place of sweating a roseo-
lous rash sometimes occurs, which is evidently a phenomenon of the
same kind produced by flushing the capillaries of certain districts
of the skin with blood through relaxed arteries. The circumstance
whether the hyper£emia aifects the superficial strata of the skin or
the deeper is probably one of the causes which determine whether
there shall be a roseola or a diaphoresis. I think that no one can
observe such cases as those I have related, and which it is difficult
to describe fully, without being struck by the confirmation they
aff'ord to the doctrines stated at p. 25 et seq. The phenomena in
some instances are as instructive as any experiment.

There is one symptom I have not mentioned which is extremely
well marked in many cases of this fever. It is met with certainly
in other morbid conditions, but yet it is a valuable sign, and may
aid materially in establishing the diagnosis. Wherever it occurs I
believe it may be taken as an indication that there is considerable
nerve debility. The symptom I refer to consists in a peculiar dark
rather broad rim beneath the lower eyelid, deepest in tint near the
inner canthus, and gradually lessening in shade as it curves outwards.
It is most evident in the early part of the day, and would not I think
be observed when fever was present. As to the cause of this ap-
pearance I am uncertain; it may be owing to actual discoloration of
the skin in this part with morbid pigment, which becomes more
evident when there is pallor of the surface. The disappearance of
the dark rim as recovery ensues would, however, be against this
view.

This fever is evidently not identical with the classical remittent
fever of children, which is usually regarded as typhoid. The latter
is, in my experience, far from being a common aff'ection, while the
one we have been considering is decidedly frequent. The influence
of remedies is besides so marked in the malarioid fever that it cannot
for a moment be ranked with typhoid. I have made no post-mortem
examinations, but I cannot conceive that they would strengthen
essentially the evidence already adduced. The term malarioid is,
I think, quite justified both by the character of the phenomena and
the marked success of quinine. The occurrence of such fever is a
further evidence of the existence of aguish miasm of actual London
origin. As to season of the year, there has not appeared to be a
very marked prevalence in one period rather than in another. In
the last three months of the year it seems to be more frequent than

296 MALARIOID DISORDER.

in April, May, or June, and about as frequent as in July, August,
and September.

The following history is, I think, one of much interest, though it
will seem to many at first sight that it has little claim to be placed
in this volume.

No. 169. — St. C, set. 3J years, m., ad. May 9th, ill three weeks. The
abdomen has gradually enlarged without pain or tenderness ; no other mor-
bid condition preceded except some failure of health. The feet and legs are
natural. The abdomen is dull and fluctuating, is considerably distended;
when he is turned to one side the upper does not become resonant, there is
resonance only in the epigastrium. The liver does not descend below the
ribs. All the time he has been ill his appetite has been lost, and he has
emaciated much. Heart's sound normal. Natural breathing in both backs.
T. clean. Urine not free, not red. B. much relaxed five or six times daily.
Another child died lately with large abdomen in two days. The urine ex-
amined three days later was scanty and lateritious, but free from albumen.
On May 23d the urine was very alkaline, scanty, and thick, deposited phos-
phates, and contained a vast deal of carbonate of ammonia. The quantity
of peritoneal effusion was undiminished. He slept very sound and perspired
very much at night. May 30th. Urine still alkaline, and effervescing
strongly with nitric acid. Appetite now very great, is always asking for
food. June 9th. The urine was more free, acid, and not albuminous; his
health was much improved, and the quantity of fluid in the abdomen had
very much diminished. July 7th. Discharged, perfectly well, better than
he was before his illness. The treatment consisted at first of gray and
Dover's powder, aa gr. ij ter die, with iod. pot. and nitre mixture ; after three
days this was changed for a diuretic mixture containing digitalis and ungt.
hydrag. to the abdomen, as the bowels were very relaxed and the stools
green. Four days later iodine was painted over the abdomen in place of
the mercurial ointment, and diuretics continued. Two days after this things
were getting worse; he had passed no urine for twenty-four hours; the skin
was blistered by the iodine. I thought the kidneys must be congested, and
ordered a blister to each loin, and ant. pot. tart. gr. \ ter die. Three days
later I had to omit this medicine, and I prescribed gr. j of quinine o. n. In
two days there was some improvement; the urine was then as stated above
on May 23d ; I gave then in addition tr. ferri muriat. n^^v ter die, which
he took up to the time of his discharge.

Remarks. — At the time when I treated this case I knew much less about
nerve disorder than I do now, otherwise I should have given iron and quinine
much sooner and more boldly than I did. I suppose I need not say that I
should not often advocate such remedies alone in dropsy. But this was a
peculiar case in which the ascites had come on without apparent cause,
where the kidneys and heart appeared to be sound, where, as the event proved,
there was no peritoneal tubercle, but where there was, as the alkaline
ammoniacal condition of the urine showed, great depression of vital power.
Moreover, there was diarrhoea, which, in the absence of inflammatory dis-
order or organic disease, may be fairly referred to paresis of the vaso-motor
intestinal nerves. From some peculiarity in the child's system the peri-
toneal vessels became similarly aff'ected to those on the mucous surface, and
serous effusion ensued. It is quite clear that perseverance with diuretics
would most likely have destroyed life, and would not have removed the

i

MALARIOID DISORDER. 297

dropsy. Tonics, on the other hand, by raising the general power and con-
tracting the relaxed vessels, had the desired effect. The case was, I believe,
one of obscurely-developed malarioid remittent. It is well known that
dropsy is not an uncommon sequel of intermittent fever. Flint* mentions
that in ten cases out of twenty-two of ascites the dropsy had supervened on
more or less numerous attacks of this disorder. He thinks with regard to
ascites generally that more success will be attained by resorting early to tap-
ping, and relying more on tonic medicines, iron and quinine, than by con-
fining treatment to the use of diuretics and hydragogue cathartics. The
spontaneous decomposition of the excretions has been well pointed out by
Dr. Inman as a sign of failing vital power. It was present very markedly
in this case, and was no doubt the cause of the highly ammoniacal condition
of the urine. There was no mucus in the fluid to act as a ferment; the de-
composition can only be referred to an alteration of the normal properties
of the secretion itself. Lastly, I would observe how strongly the case testi-
fies against prescribing according to the mere name of a disease, and how it
sets forth the necessity of studying the pathological condition existing in
each case, as well as the "Isedentia" and "juvantia."

The next subject I propose to notice refers to a disorder essen-
tially similar to that we have just considered, but presenting usually
much less distinct symptoms, and affecting adults. This is the " ob-
scure remittent" of Dr. Macculloch, which is often a very anomalous
and difficult disorder to deal with. Persuaded as I am that such a
disease exists, and is not very rare, I feel strongly the need for so-
briety of judgment and careful investigation before concluding that
in any given instance the disorder is really of this nature. As the
nervous system is prominently affected, as the febrile manifestations
may occur at night and seldom perhaps be well marked, as the dis-
order is chronic and often obstinate, and apt to be attended with
anomalous symptoms, it is no wonder if the perplexed practitioner is
much disposed to vote it all hysteria or hypochondriasis. I must
refer here to the section on hysteria for the grounds on which our
diagnosis from that state should be based, and will only remark that
we should be cautious in using an ill-understood term to designate
that which we feel ourselves to be obscure. Of course due pains
should be taken to discover any existing organic disease, or any
pernicious habit, or consuming mental distress, which may account
for the bodily suffering. Supposing, however, that none of these
can be detected, or appear adequate to explain the morbid phe-
nomena, it is well worth considering whether the patient be not
labouring under this form of malarioid disease. Besides the possi-
bility of the disorder having originated in London, which has been
proved by the evidence I have adduced, it should be considered how
very practicable it may be for an individual on a journey of business
or pleasure to "pick up" an aguish taint at some place where the
causes of it are rife ; and those who have most experience of such mat-
ters I believe will agree with me that, like syphilis, such a taint once

1 "Amer. J. of Med. Sc," April, 1863.

298 MALARIOID DISORDER.

contracted is with difficulty ever shaken off, at least as long as the
subject of it is exposed to the wear and tear of an ordinary active
business life. The existence of the obscure remittent among us is
fully recognized by Dr. Copland, whose world-wide experience of
the morbific action of malaria makes his testimony peculiarly im-
portant. Writing about 1850, he states that he believes malaria to
be far oftener present than has been imagined, more especially of
late years, and around the metropolis. He adds that " by mistaking
this fever for other diseases the sufferings of the patient are often
materially aggravated, whilst having recognized its nature and cause
not only the means of cure, but those of prevention become obvious."
Between cases of a milder and more obscure character there intervene
all grades up to those where the symptoms of bodily disease are
evident and striking, although the nature of the efficient cause may
be matter of great question. I proceed to relate sundry cases in
illustration of this subject, taking first those of the more positive
stamp just alluded to.

No. 170. — Gr. R., set. 32, a carpenter, ad. July 19th. Grenerally has
good health, has been ill three weeks. He was first attacked at Dover with
shivering occurring every night followed by violent sweating; he had pains in
the knees and soles of feet. He still shivers every night more or less, but
has no sweating. He complains of debility, pain at the back of the head,
and exhaustion on the least exertion ; has bad nights, no appetite. The
pulse is very feeble, the tongue covered with white-capped papillae, skin
cool. B. costive, urine dark coloured. Has pain across loins and in the
left shoulder. The stomach and intestines are shrunken ; there is no en-
largement of spleen or liver. The thoracic organs are healthy. Pot. iod.
with ammon. carb. and tr. cinchon. was given at first for three days, besides
two doses of calomel and colocynth, but without any advantage. 22d. The
stomach can retain only milk and beef-tea; there is no epigastric tenderness.
He is so feeble that he can hardly stand. Quin. disulph. gr. iij ter die.
25th. Somewhat better. P. very weak. Urine exceedingly dark coloured.
Pt. c, quin. quater die. Chop and porter. From this time he went on
steadily improving, and was discharged well Aug. 12th. As he improved,
the urine became of a much lighter colour.

This man undoubtedly had quotidian fever, though while under my care
the febrile symptoms were but slightly developed. It would be more exact
to say that he was under the toxic influence of malaria, which caused the
remarkable prostration. It did not appear that there was any other cause
for this extreme debility, and the speedy way in which he rallied under
treatment founded on this view confirms the opinion. The source of the
poisonous miasm was by no means clear ; if produced at Dover, as seems
most probable, it certainly suggests the possibility that other towns may have
the same undesirable privilege. The very dark colour of the urine, while
the spec. gr. was moderate, shows that considerable waste was taking place
in the blood-globules, whose decay furnished the abundant pigment. The
arrest of this decay by quinine is a fact I have often observed ; it seems to
indicate that this wonderful nervine acts in part through the nerves on the
blood in the vessels, diminishing over-active vital changes. The beneficial
action of alcohol in acute disease is probably of the same kind.

MALARIOID DISORDER. 299

No. 171. — W. C, m., aet. 32, excavator, ad. Sept. 16th. Ill four raon.tbs;
his illness came on gradually. I have no note as to his having been in any
known malarious locality; my impression is that he had not. He seems to
get worse every week. Aspect ansemic. Has the appearance of a man
affected by some serious disease ; his speech is slow and hesitating, and his
whole manner of the same kind. Has headaches at night. Is very ill in
the morning, can hardly draw his breath, and has cramps in the legs. Takes
food fairly. Not much cough or expectoration. Skin cool. Feels very
weak. P. feeble. Heart and lungs sound. Quin. disulph. gr. v ter die.
In three days he was much better ; at the end of seven he was still improving,
and some neuralgia had appeared in the left frontal nerve. Soon after this
he ceased attendance. This man had never had ague, and there was really
nothing distinctive on which to found a diagnosis. The absence, however,
of any organic disease which could account for the great prostration was
strong ground for regarding the system as labouring under some serious
toxic influence, and, as the symptoms did not appear to be those of the
ordinary continued fevers, it was reasonable to attribute them to malaria.

No. 172. — Mr. S., set. 40, seen Aug. 24th. Was born and lived at Wis-
beach twenty- two years ago; never had ague. He has suffered from catarrh
five weeks ; bowels have been loose until the last few days ; has a hollow
cough, almost dry. Is emaciating much and losing strength. Has drench-
ing sweats at night. Skin damp. P. weakish. Lungs emphysematous, heart
displaced and liver lowered. Last four days has had pain across upper ab-
domen, not increased by food. With quinine + iron in pretty full doses
he recovered, but his improvement was slow. It is not uncommon to meet
with cases in which by day there are only symptoms of general debility,
while at night some special phenomena of nerve disorder ensue. In one
instance a female, set. 32, stated that she woke up with a shivering fit at
night about 1 A. M., the rigor lasted ten to fifteen minutes, was attended
with palpitation, and succeeded by faintness and a sense of dread. With qui-
nine gr. iv at 6 and 9 P. M., the attacks ceased. Another, a3t. 31, after
an asthenic bronchial catarrh complained of having much palpitation, which
came on very often at midnight ; she awoke up in trembling and perspira-
tion. Another, aet. 40, who had been ill about four months, and had sick-
ness and violent retching of a morning with some bowel disorder, described
herself as waking up in bed at night in a state of semi-syncope. She bene-
fited very much by quinine and change of residence from the vicinity of a
canal.

No. 173. — X. Y., a strong-made medical man, ast. 40, until lately resident
in the country, where he had for a long time been overworked, especially with
midwifery at night. He suffered from irritability of the urethra at interval,",
especially after great fatigue. His great distress now (June 13th, 1859) is
from shifting rheumatoid pains, which remain scarcely more than two days
in one part, but during this time make the affected part very tender and
sore; they haunt the loins, hips, and shoulders. Muriate of ammonia has
been taken, but without benefit. He takes food tolerably well. Urine = 40
oz. in twenty-four hours, sp. gr. =1020, contains no uric acid. He com-
plains of exceeding exhaustion ; is even unable to read, which he is usually
very fond of. His nights are wretched ; he gets out of bed more than
twenty-times to change his position, as he is unable to turn in bed. Much
perspiration at night. T. flabby. P. soft. Skin cool. A fortnight later,
after he had improved in the interval, he had two very bad nights ; the last

300 MALARIOID DISORDER.

was particularly bad. He had not ten minutes' sleep from distressing mus-
cular spasm almost like tetanus, sucb that while lying on his back he could
not breathe, and was compelled (though no chicken) to shed tears. When
I saw him his pulse was open and very soft, and his skin damp. He told
me that at night the part of the bed where he lay was so drenched with
sweat that it might literally have been wrung out. I advised him to take
gr. X of quinine at bedtime and two hours previously. He took this, went
to bed, and lay quiet without spasm, but did not sleep for two or three hours ;
then he took 3 full glass of port wine and slept well for three hours, after
which he awoke, took more wine, and slept again, so that he had a fairly
good night. July 11th. Has been taking about gr. 20 of quinine every
night and wine; has decidedly improved, but feels sore and stiff in various
parts, and perspires copiously still. Urine deposits uric acid now pretty
freely, the twenty-four hours amount = 5.53 grains. Relishes his port wine
greatly and longs for it. 12th. Was quite delirious last night, and is exceed-
ingly shaky to-day ; walks tottering, and feels as if he should fall. 21st. For
some days has had ferri et quin. citratis gr. x -f tr. arnicse rti xv ter die, and
is greatly better, sleeps better. 26th. Last few nights not so good. Quin.
disulph. gr. v, his die, and gr. x 0. n. 28th. Is quite jolly and strong; two
excellent nights ; some rheumatism with swelling about ankles. Aug. 27th. Has
been going on very well, taking gr. x to xx of quinine daily until this morning
when severe purging and vomiting set in ; he passed a gallon or more of
pale liquid; had cramps in abdomen, and felt chilly and depressed. Purg-
ing stopped by sulphuric acid, spt. seth. s. co., and tr. opii. Thinks he is better
than he has been for between two to three years, but still has the severe
pain at night in the muscles of the back, which prevents him from turning in
bed, and forces him to get out at the one side and in at the other. Sept. 17th.
Is in greatly better health than for a long time, in excellent spirits, gaining
flesh; has better nights, but still requires wine, and has to get out four
or five times to change his position. He can walk but little. His bladder
is much less irritable than it used to be; it will hold now 9 ounces, whereas
last year it would only hold 3 ounces at a time. Oct. 5th. His chief com-
plaint is now of his feet, which get very swelled and painful at night, more
so than they used to be. They are easier after a night's rest, but very stiff,
and do not subside to their normal size. Occasionally when he has had
sharp sciatic pain the feet have been much better. Dec. 13th. Feet exceed-
ingly tender and painful, so that he can barely walk; no quinine taken for
a long time. Much depression. Pot. iod. gr. iv + ammon. carb. gr. v +
tr. cinchon. 5jss + dec. cinchon. Sj ter die. Sulphur-fume bath. 17th.
Can walk now very much better. March 20th, I860. Is now so far re-
covered that he can walk six miles without much inconvenience. He sleeps
sound for five and a half hours at night, but is obliged to be lightly covered
and to have the window open to avoid sweating. I have often seen him
since, and know that he is in fair health.

Remarks. — The exceeding causeless exhaustion, the great depression,
the sleeplessness, the muscular spasm, the drenching nocturnal sweats, the
delirium on one occasion, the beneficial eifects of quinine and wine, and the
asthenic rheumatic affection are very noteworthy points in this case. Mere
asthenic rheumatism it certainly was not. Some toxic influence must surely
have been at work so to prostrate a robust system which had long success-
fully battled with difficulties. This could hardly have been the less healthy
atmosphere of London, because the effect of this would have been less acute

MALARIOID DISORDER. 301

and would rather have increased than diminished as time passed on. That
the nervous system was especially affected was clear both from the symptoms
and from the good effect of persistent tonic treatment. The under-current
of rheumatism, which became so prominent as the symptoms of debility and
prostration gave way, seemed to me to have a common cause with the rest
of the disorder; reminding me very much of the case of a relative of my
own who was invalided and sent home from India for subacute rheumatism,
but recovered completely by the change to a colder climate. In this and
many like instances nerve-debility, however occasioned, goes for very much
more, I am persuaded, in the treatment of disease than any materies morhi.
It is very worthy of notice that while the uric aid was absent from the urine
at the time of the greatest depression, it increased and attained to a tolerably
good figure as the general condition amended. This I have observed in
other similar instances. It is by no means only in gout that the uric acid
is deficient in the urine ; this is also the case in various conditions where
nutrition is much impaired. The patient was a man of more than average
fortitude, endui-ance, and intelligence, and a better instance could scarcely
be adduced of the severe and long suffering inflicted by this obscure malady.
\Yith a feebler system, or a less courageous spirit, I think it far from im-
probable that mental derangement might have ensued.

No. 174. — G. G., set. 20, m., ad. Dec. 30th. Has a cough always in
winter, father and mother died of phthisis. Ill one week, suffers with cough,
great weakness, anorexia, night sweats. Does not sleep well at night, but is
always drowsy. No dulness or morbid breath sounds under clavicles, some
large bronchial rale in left lower back, none elsewhere. Never spit blood.
Has now a good deal of expectoration. P. feeble, but distinct. T. rather
coated. B. open. Urine rather high coloured. Is now bathed with perspi-
ration, but is cold. Till to-day did not appear ill as at present, about noon
became affected with faintness and perspiration. He appeared so seriously
ill that he was made an in-patient under one of my colleagues. Dover's
powder was given at night, and on Jan. 1st mist. spt. vini gall, was ordered.
His further history is as follows. On the night of Dec. 31st or next morn-
ing he had three convulsive attacks, two slight fits and a severe one, was
convulsed and became black in the face. He remained insensible all Jan.
1st, and did not speak; after an enema he appeared better. On Jan. 2d he
appeared much better, was quite conscious, had appetite, and was well up to
11 P. M., when the sister left the ward, got in and out of bed to the
night-chair by himself. Soon after this he changed, became delirious, was
noisy and moaning, sank and died quietly about 9 A. M., of 3d. — P. M., on
Jan. 6th. Brain, heart, kidneys, liver, spleen, and stomach normal.
Lungs engorged at back part, crepitant, no tubercles anywhere, but a soft
cretaceo-fatty mass lay in the root of right lung. Thymus gland large.
Supra-renal capsules enlarged, very firm, converted into firm scrofulous mat-
ter of marked yellow colour internally with spots of cretaceous deposit.
Externally there was found a peripheral layer of grayish more translucent
stuff consisting of fibroid stroma loaded with nuclei mostly round, and con-
taining some groups of small masses of translucent homogeneous fibrin
('speckig,' or bacony matter). The more yellow or opaque part is far ad-
vanced in fatty degeneration. The hair was curly, of demi- woolly appearance.
The body had much of the dark tint of a mulatto ; the penis and scrotum
were large and very dark.

Remarks. — The above was no doubt a case of Addison's disease, but yet
20

302 MALARIOID DISORDER.

it seems pretty certain tbat the patient did not die of that disease. The
peculiar intermitting and ultimately fatal nervous aifection must, I think,
have been the result of some toxic influence acting ab externo on a system
predisposed by existing organic disease to be dangerously depressed. The
day I saw him, Dec. SOth, he was seriously ill and prostrate, the next day
he seems to have been better, the day after he has severe head symptoms,
the fourth day he is much better, and on the fifth he dies. This is much
more like the doing of a pernicious fever than of uncomplicated supra- renal
capsule degeneration. The latter alteration must have been of long standing,
while the disorder which destroyed life seems to have commenced about
twelve days before death as a bronchial catarrh. The same conversion seems
to have occurred in this case as in No 104, p. 220, where a similar aifectiou
transformed itself into a remittent fever with arterial spasm. Here again
we have glimpses of the connection subsisting between influenza and mala-
rious disease.

No. 175. — Mr. H., set. 48, seen in consultation with Dr. Palmer Jan,
29th. He is a weakly man with feeble heart and emphysematous lungs.
No valvular disease or hypertrophy. Insanity is hereditary in his family;
his father died insane. Is a coach painter, no blue line on his gums. Has
had neuralgic attacks the last fourteen days, had erysipelas before, The
neuralgia began, while there were still remains of the erysipelas ; it affects now
both calves, and extends sometimes downwards to the feet. It comes on
regularly every twelve hours at 1 A. M. and 1 P. M., and also is brought on
by exertion, as in standing upright. Some similar pain has occurred in the
situation of the biceps brachii muscle, and in the forearms, on both sides.
The painful parts are not tender on pressure. Urine full coloured, clear,
not albuminous. Agreed to give quin. disulph. gr. v quater die, and ferri
carb. saccht. 9j ter die. Feb. 5th. His legs have been well now for three
days, but he continues to suflfer much in the arms and forearms, and also
has shown distinct symptoms of insanity ever since the legs got well. For
the last four days has had tr. opii ttl 20 with each dose of quinine. 9th.
Intellect more normal; pains shifting about, and less severe; both hands
swollen, showing indications of rheumatism. Urine turbid and lateritious,
deposits uric acid when treated with nitric. Gets very weak, can hardly
move in his bed. Appetite very bad. Becomes very faint at night. Pot.
iod. gr. viij, pot. acetat. gr. 20, spt. seth. nitr. Jss, mist, camph. ^j ter die.
Pulv. Doveri, gr. x h. s. o. n. Wine and nourishment to be given freely,
12th. Pains much relieved, and has less faintness, is calmer. There is, how-
ever, marked ansesthesia of the feet, and complete paralysis of the right fore-
arm muscles, so that the hand hangs powerless; the left hand being also
paralyzed, but less completely. 14th, Is very much worse, rheumatic swell-
ing gone, complete anaesthesia of the feet, and some way up the leg ; same
condition of hands and arms some way above elbows. Numerous petechial or
purpuric spots on knees, feet, trochanters, and hands. Radial pulses barely
to be felt, crural quite distinct and of fair apparent force. Sounds of heart
very feeble. Is perfectly conscious. Tongue moist at edges, dry and black
in middle. Bowels relaxed very much each night, not by day. Abdomen
rather distended, right iliac fossa tender, distinctly more so than left. No
unequivocal rose spots, one doubtful one. Both hands and feet quite power-
less. Has taken a bottle of port wine daily the last two days besides Oss of
brandy. In the evening vomiting began, everything was rejected ; during

MALARIOID DISORDER. 303

the night, he had no diarrhoea, but the vomiting continued in spite of ice.
The asthenia gradually increased, and he died on 16th.

Remarks. — It was certainly desirable to have had an autopsy in this
case, and yet I doubt whether it would have thrown any light on its ob-
scurity. The patient, always a feeble individual, and having an hereditary
tendency to nerve disorder, died in the uttermost state of adynamia after
having presented a series of completely ataxic phenomena mainly referable
to the nervous system. Erysipelas, periodic neuralgia, cerebral derangement,
rheumatism, and paralysis of the extremities as to motion and sensation pre-
ceded the final collapse, during which, however, at least up to two days
before death, the functional power of the brain had returned and was active.
This picture is certainly not that of any of the recognized continued fevers of
this country, nor do I think it is at all proved that the symptoms were the
result of a malarious poison. Still the phenomena appear to me to point
more in this direction than in any other. The tenderness in the right iliac
fossa might certainly be the result of such intestinal ulceration as occurs in
typhoid fever, but it might also occur from disease independent of this fever,
as from inflammation and ulceration of the follicles of the caecum and
colon similar to that which is apt to ensue in dysentery. The agminate
glands of the small intestine, according to Dr. Morehead, are affected in some
eases of remittent fever. He gives two cases in his work (vol. i. p. 146, 157),
in which Peyer's patches were enlarged and ulcerated. The nocturnal occur-
rence of the diarrhoea, the paralysis, the rheumatism, and the clear state
of intellect two days before death are phenomena quite unlike those of typhoid
fever. There is nothing to show that he was under the influence of gouty
or lead poison. The periodic character of the neuralgia, and its replacement;
by rheumatism, while this again was succeeded by peripheral paralysis, are
circumstances which are often paralleled in instances of malarioid disease.
The previous erysipelas had no doubt further lowered the power of his
originally weak system, and to this debility the severity and fatal tendency
of the disorder was probably due rather than to any especial malignity in
the efficient cause. Without asserting it as my settled opinion, I have
long suspected, and I think there are some grounds for the view, that a form
of fever exists which is neither typhus, typhoid, relapsing, nor febricula,
which is more or less continued, and is allied to influenza, rheumatism, and
malarious diseases. Of this I am disposed to think the following was an
instance.

No. 176. — Mrs. T., seen August 15th, 1863. A married lady, resident
in South Belgravia a short distance from the river, the smell of which she is
persuaded affects her during the months of July and August. She has had
four children in quick succession, and suckled the last- seven months. She
exposed herself to a chill during very hot weather, and was attacked with
febrile symptoms, which increased for a week, and then obliged her to take
to bed. When I saw her she had been ill fourteen days, and confined to
bed the last seven. She was perfectly rational, and her countenance did not
present the aspect (5f stupor. Her symptoms had been a very coated tongue,
prostration, very high-coloured urine, loss of appetite, thirst, and frequent
great flushing of the face and head in paroxysms, with succeeding perspi-
rations. She had no splenic enlargement, nor hepatic, no decided tender-
ness in the ilio-csecal region, very little diarrhoea (one day). There was a
pretty copious papular eruption on her chest, the papules lowering down to
spots on the abdomen, some of them resembling rose spots, but being rather

804 MALARIOID DISORDER.

larger; on the 16tli this eruption had faded a good deal. She complained
then of tenderness about the right upper part of the neck, and just behind
the right ear, there was very little of any swelling. On 15th about 8 P. M.,
her pulse was 117 j tongue red, denuded, moist, coated towards the base.
On 16th at mid-day, the pulse was 96, skin cool and soft. The bowels,
which had been confined four or five days, had been opened by a water enema;
the stool was lumpy. 20th. Is gradually improving, but has considerable
pain and swelling of the right parotid gland. This swelling did not sup-
purate, but she had a long and tedious convalescence, extending over fully
three months. Towards the end of her disease evening accessions of fever
and most violent evening accessions of neuralgia were marked features of her
state. The neuralgia was centred in the enlarged parotid gland. Both
symptoms were benefited by quinine, but ultimately change of air became
necessary.

Remarks. — It must be admitted as a not impossible occurrence that this
case was au fond one of typhoid fever modified to some extent by malarious
influence. As there was no autopsy, this cannot be disproved. The condi-
tion of the patient was altogether unlike that of ordinary typhoid fever in the
aspect of face, the absence of stupor, the kind of eruption, the paroxysms
of flushing of the head, the state of the bowels, the subsequent evening
neuralgia, and the presumed cause. Parotitis may occur in remittent as well
as in typhoid fever. I wish to avoid the typhoid controversy, but I cannot
help stating that it is not demonstrated to my mind that enlargement, or even
enlargement with ulceration of Peyer's patches, is a pathognomonic evidence
of typhoid fever. I think it possible that enlargement, or even enlargement
with ulceration, may be produced by other causes, and that of such a kind
as might occur from typhoid fever. Where the symptoms during life diff"ered
considerably from those ordinarily observed in this disease, I should not
regard the state of the intestines supposing them to be aff'ected with typhoid
alterations as diagnostic^jer se. Further, with the evidence I have at present,
I cannot but think that a patient may have a copious eruption of rose spots,
nearly disappearing in five days, considerable diarrhoea, tenderness in the
ileo-csecal region, and other symptoms of low fever, and die at the end of
fifteen days without any morbid alteration being found in the intestines, or any
other organ, except some congestion of the lungs. The intestines were care-
fully examined. My creed at present is that the great majority of continued
fevers are easily distinguishable, but that the groups are not so exactly de-
fined as to make it always possible to say whether a given instance belongs
to one or to another. The case I think is similar to that of cancer and
various other disorders. The types are well marked, and distinct, but iu
proportion as the special characters are more feebly developed we get tran-
sition instances, the exact nosological place of which it is very difficult to fix.
The case I have related seems to me to have much more marked affinities
with remittent malarious than with typhoid fever.

In concluding this subject I would ask attention to the bearing of
a few facts, viz : (1) It has been shown that a cause capable of
producing ordinary ague may be generated in London, hoiv, I do
not say. (2) Children in London not unfrequently suffer with dis-
order which has the character of a remittent, or quotidian inter-
mittent, and is cured by quinine, or quinine -f iron. (3) Neuralgia
affecting various situations is not uncommon which yields to the same

SECRETION FLUXES. 305

treatment. (4) The cause which produces influenza occasionally
gives rise to inter or remittent fever and neuralgia. Now as Lon-
don is not a place well calculated for generating malaria in the
ordinary way, and as another cause appears to be capable of pro-
ducing similar phenomena, it seems to me a question that may fairly
be raised whether there may not be several causes or miasms, which,
acting on the nervous system, produce the same or similar eflfects.
When a person free from all ague taint gets a violent facial neuralgia,
which is cured by quinine in full doses, we can hardly avoid asking
ourselves the question, what is the difl'erence between such disorder
and that of malarious origin ? If the results are so like, must not the
causes be like too ? I think it may also be argued that it is certain that
some such miasmata are very commonly and widely diffused, and that
it is but reasonable to attribute to them a large share in the genera-
tion of our ordinary maladies. The results of their action are of very
various character according to the state of the recipient. Generally,
however, it may be stated that their main action consists in the de-
pression of nervous power. According to the part specially affected
the symptoms will vary : thus there may be cerebral depression, neu-
ralgia, palsy, fever, or hypersemia and exudation phenomena.

I may mention here that I have met in the course of the last year
with two cases of quartan ague, occurring in labourers. One had
contracted his ague at Deal, and had suffered with it at "spring and
fall" for ten years. The other had received his taint at Tilbury in
Essex five years previously. In the first the attack commenced
about 1 P. M., in the second at 6 P. M. In the latter, as the fever
gave way, a sharp paroxysm of neuralgia of all the divisions of the
left fifth nerve occurred, and lasted all night from 4 P. M. This
man attended six weeks, and had no attacks after the first seven
days ; he took quin. dis. gr. ij 2cZzs lioris at first, and afterwards less
frequently. The other took tr. cinchon. flav. 5ij 4^is horis ; he only
attended eight days, but had no return after the second. These are,
as far as I know, the only cases of quartan I have seen in the course
of thirteen years. A mid-aged female at present under my care has
a disorder which is apparently ague of octavan type. It has been
arrested by quinine.

CHAPTER XXXVI.

SECRETION FLUXES.

No. 177. — J. M., 3st. 28, m., ad. Jan. 14th. Ill three weeks, jaundiced,
stools of a light, urine of a dark colour. Liver rather enlarored, projecting
two fingers' breadth below the ribs. Some nausea. Sense of weight over
eyes. Has pain referred to lower sternal region, worse after food. Tongue

306 SECRETION FLUXES.

coated. No thirst. Skin cool. Pulse feeble. Has ear ache. Feels very
weak. Abdomen fallen. Hyd. chloridi gr. x statim, acidi nitro-muriat. n]_v
-f liq. taraxaci 5j + aq. |j ier die. 18th. Stools of a different colour alto-
gether after the powder; mouth sore, tongue coated. Urine clear, but of a deep
red. Podophyllin gr. \ + extr. colch. acet. gr. ij o. n. s. Pt. c. mist.
21st. Not half so yellow as he was, but still markedly so. Stools of a good
colour. Urine very red. Pulse very weak, soft. Pt. c. pil. et mist. 25th.
Urine of a deep reddish colour, evidently from bile ; stools d-ark coloured ;
pills have acted strongly, had seven motions on 23d, all darkish. Is still
jaundiced. Perspires very much in a warm room. Pulse very weak. x\p-
petite poor. Tongue coated. Seeing that though there was free bile flow
into the intestine the jaundice continued to manifest itself in the skin, eyes,
and urine, and that there was evidence of considerable debility, I thought it
probable that the condition was one rather of bilious flux than of biliary
retention or suppression, and I prescribed accordingly. Twelve grains of
quinine were given daily. In three days there was improvement; in twelve
days there was scarce any trace of jaundice; the urine was clear and of a
natural colour, the stools rather light coloured. Nitric acid still detected a
little play of colour when added to the urine. He was treated subsequently
for another month on account of ear-ache (neuralgia) and cough, and was
discharged on March 10th feeling as well and strong as ever he did. He
had no cholagogue, or aperient medicine after he began the quinine.

Remarks. — My first acquaintance with the above kind of disorder was in
the case of an ofiicer serving in the Crimea, who was highly jaundiced, but
passed at the same time a large amount of bile in his stools. " Lots of blue
pill and calomel" were given, as well as some emetics, to get rid of the bile,
but it appeared to him " that he made more as fast as it was carried away."
During his voyage to England the jaundice disappeared, but remittent fever
came on and increased so much that he was much more seriously ill when
he reached his destination than when he embarked. When he came under
my care at home he was greatly prostrated, quite unnerved, and had noc-
turnal paroxysms of fever accompanied with determination of blood to the
head. Quinine with change of air restored him. In cases of jaundice of
this kind the probability is that the nerves of the hepatic plexus are para-
lyzed, and that in consequence hypersemia ensues and increased functional
activity. Salivation to some extent may be produced in the same way.
Cutaneous fluxes are quite common in connection with malarioid disorder.
The nocturnal sweating of phthisis has been rightly interpreted by Dr.
Inman as the result of exhaustion, and, as I believe, dependent upon vaso-
motor paresis. Anything which causes great nervous prostration is apt to
give rise to sweating. It is worth remarking that in the case above recorded
there was debility and a neuralgia (ear-ache) from the first, and that he was
very readily affected by the single mercurial dose. These are all indications
that the nervous power was below par. The patient was a rather strongly
made man. Dr. Copland notices jaundice from exuberance of bile as one of
the forms of the disorder, and refers to other authors who have described it.
I have recorded in the Med. Times and Gaz., Feb. 7th, 1863, a case in which
this condition succeeded to one of inflammatory congestion. The practical
value of correct pathological views is very apparent in such instances.

HYSTERIA. 807

CHAPTER XXXVII.

HYSTERIA.

It seems to me quite necessary in a work professing to deal with
disorders of the nervous system to take some notice of the above-
named state. The term is confessedly not a very definite one, and
it will be, I think, worth while to consider what meaning is gene-
rally attached to it as used by the profession. Dr. Prout states
that "in hysteric cases the utmost duplicity and cunning may be
displayed, where from mere appearances we should expect nothing
but the most rigid truth — in short, the whole energies of the patient's
mind are bent on deception." Her innate desire being to become
an object of attention, if she fail to accomplish this by inspiring love,
she falls back on the endeavour to excite commiseration. Dr. Wat-
son writes : " The deceptive appearances displayed in the bodily func-
tions and feelings find their counterpart in the mental. The patients
are deceitful, perverse, and obstinate, practising or attempting to
practise the most aimless and unnatural impositions." I believe that
the majority of the profession agree with these statements, and that
the term " hysterical" is commonly used to designate a patient whose
complaints are considered to be more or less exaggerated, and who
is not ho7ia fide anxious to get well, and cease from being the object
of nursing and sympathy. Dr. Copland considers increased reflex
excitability of the nerves of the female generative organs as one
principal causative condition of hysterical affections, and Romberg's
opinion is nearly the same. The latter says : " From the time when
hysteria has taken root, the reflex action preponderates throughout
the organism and renders the individual more dependent upon ex-
ternal stimuli." He says, however, naively, when speaking of
spinal irritation, " The patients generally being females, much de-
ception is practised upon the medical man !" It seems to me that
this view fitly applies to the bodily condition which is present in
many hysterics, though not, I think, in all, but that it by no means
sufiiciently regards the psychical. An erethysm proceeding from the
generative apparatus might, I can well conceive, give rise to eroto-
mania ; or to various spasmodic quasi-choreic aff"ections, but hardly
to the peculiar mental state which Prout and Watson recognize so
fully, and which my own experience certainly leads me to look upon
as the fundamental malady of the truly hysteric. There seems to
me to be very little evidence in favour of the view that hysteria is
the result of ovarian or uterine hyperaesthesia ; in fact I should say
the evidence of cases where such hypersesthesia is present is opposed

808 HYSTERIA.

to it. It does not appear that females suffering with irritable uterus
are more hysterical, often not so much so, than those who have no
such disorder. Neuralgia of the ovaries is certainly a rare affection,
very far more so than hysteria. All experience proves that much,
I had said almost any, local treatment is injurious in real hysteria,
but this would surely not be the case if Copland's and Romberg's
theory were true. The point in question is one of most practical
interest. If the essence of hysteria is a disorder of reflex excitability,
it is as much a bodily disease as tetanus or chorea, and ought to
have its cure attempted by remedies addressed to the deranged
nerves or centres. But if the disorder au fond is what Prout repre-
sents it, then it must be apparent how futile such procedures must
be. In arguing thus I take, as I think I have a right, typical forms
of disease for instances, while I am quite ready to admit that there
may be many intermediate morbid states compounded of various
measures of bodily and mental disease. Having stated thus what
seems to be the prevalent and to a great extent the correct opinion
on this subject, I proceed to lay down and illustrate a limitation of
it, viz., that the most marked and characteristic hysterical phe-
nomena (according to ordinary parlance) may occur as the result of
severe strain or exhaustion of the general nervous system in persons
who are' thoroughly honest, and have no morbid craving for sym-
pathy. I will briefly relate a case of what I consider to be gen-
uine hysteria, and then three cases of what I think would be falsely
termed so.

No. 178. — M. K., set. 27, f , ad. Sept. 12th. Has aphonia, can only
speak in a whisper. Lies in bed with both legs crooked up with the heels
against the buttocks, complains very much of pain when any attempt is made
to straighten them. The limbs are rather but not very much wasted. Says
that ten years ago she fell down and hurt one leg, which then became drawn
up ; two years ago she took cold and the other leg followed, and both have
remained as at present ever since. Cannot pass her urine freely, she says, but
on being examined is found to have passed a quantity under her. Chloroform
was administered, and as soon as she became insensible the legs were
brought straight down with perfect facility, and being thus disposed they
were tied to the bedposts. 16th. Has scalded her face and mouth pretty
smartly with boiling water on purpose; she was found with it. Sent out
soon after. This girl was determined to be ill in one way or other, and as
she was not allowed to persevere in her first plan she adopted another.
Clearly it would have been futile to have given her physic, unless perhaps it
had been the " infusum henedictum," which was once found effectual in
curing a number of malingering soldiers, and which was compounded of a
weak infusion of tobacco and Epsom salts ! !

The following cases are of a very different stamp : —

No. 179.— F. U., f., set. 30, single, ad. April 20th. Ill three years.
Has no strength, legs are weak, feels suffocated at times, more so at night.
Her throat is not sore, but her voice is weak. When the suffocative attacks
come on her legs give way and she drops. At times she becomes quite

HYSTERIA. 309

unconscious for a few minutes. Gets worse at the end of the week, is better
for the Sunday's rest. Works from 7 A. M. to 12 at night in a laundry.
P. weak. T. clean. Ordered strychnia + tr. ferri muriat. + chloric
ether ter die. May 4th. Has been better, but had a bad attack of choking
and suffocation on 30th, when catamenia were present ; ''is always worse at
those times." She continued the same mixture, or a very similar one, up
to July 6th, and improved very considerably, so that the attacks occurred
much more rarely than they had done; she had been without any when last
seen for fourteen days.

Remarks. — These attacks must have had much of the outward appear-
ance of hysteria, since she herself described them to me as such. Yet surely
there was cause enough in the unhealthy and excessive toil she had to endure
for almost any amount of nerve disorder. Which of us, I should like to
know, would not have collapsed under a long continuation of it? In spite,
however, of her unfavourable circumstances, she rallied bravely, and gladly
acknowledged the improvement in her health, the last thing which an hys-
teric is inclined to do.

The next case is similar.

No. 180.— E. S., a3t. 17, f., single, ad. Sept. 22d. Ill twelve months,
had improved, but has relapsed last three. Is hysterical, the attacks come
on at the monthly periods ; she becomes giddy, very nervous and weak at
the chest, and goes off into convulsions at those times. The heat of the
laundry-work seems to bring on the attacks. She takes food fairly, does
not seem hyperaesthetic. T. coated. B. costive. With iron and quinine
she improved steadily and satisfactorily during a period of more than two
months.

No. 181. — Mrs. A , jet. 35, seen June 28th, a very sensible calm

person of well-regulated mind. Has not been feeling well for some days;
her power of attention and her memory is impaired ; cannot read as usual.
Over-fatigued herself yesterday. Is now suffering severely with headache
referred to the vertex compared to a heavy pressure, and darting through
the head at times. Head not hot. Has much difficulty to restrain herself
from "hysterical crying," finds a lump rising in her throat. Headache not
increased by lying low. Had scarce any sleep last night. No appetite at
all. With tonics and country air she soon got quite well.

Now it needs no argument to prove that these last three cases were
totally different from the first, and different in the most important
respect, viz., that their " morale" was healthy and sound, and that
they were really desirous to get well. With the first mental per-
version was almost the sole disorder, and I verily believe that the
old treatment of lunatics, viz., a sound whipping, would have done
her more good than all the drugs in the British Pharmacopoeia.
But the latter cases had much more of the commonly-recognized hys-
terical symptoms, viz., globus, crying, choking, and paroxysms of
unconsciousness, than the first. Any practitioner would have called
them hysterical, as indeed they called themselves. But it is plain
they were not hysterical in the sense in which the first case was.
Such, however, is the force of terms that I suspect very few would
have acquitted them of some degree of the same mental perversioa

810 SYPHILITIC AND RHEUMATIC NERVE AFFECTIONS.

■which characterized the first. Now this I hold to be an injustice
against which I protest. According to the received use of the term
hysterical among us, no one should, I think, be so designated whose
mind is free from all exaggerating tendency, and who would scorn
to practise malingering. Call them, if you please, weak-nerved,
enfeebled, hypersesthetic, or neurolytic, or anything which implies
that solely their physical mechanism is failing and out of gear, but
cast no suspicion on their immaterial part, perhaps braver and
stronger than your own, which may never have been tried as theirs
has. No doubt there are many cases of a mixed kind, where, to-
gether with real nerve debility and distress, there is more or less of
mental infirmity, disposing the sufferer to exaggerate, or to make
the most of their maladies. If, however, no proof of imposition can
be discovered, and if the history of the patient shows that she has
had much wear and tear of the nervous system, we should be slow
to set her down as an hysteric because she has the classical symp-
toms more or less markedly. I speak from self- condemning recol-
lections of patients whose complaints I had got weary of hearing,
and whom I had come to set down as inveterate complainers not to
be benefited by anything, who yet after a time have rallied, and
shown that it was mere physical disorder which depressed them, and
that there was no want of honesty. This, after all, is the main
point; let a patient be but really anxious to get well, and there is
fair hope of dealing successfully with her nervous disorders, however
complicated they may be. But when the medical attendant once
finds that disorder is simulated, or greatly exaggerated for selfish
purposes, he had better conclude that moral treatment is needed and
not medical.

CHAPTER XXXVIII.

SYPHILITIC AND RHEUMATIC NERVE AFFECTIONS.

It is a question of considerable importance, but which I have no
means of answering from my own experience, whether the syphilitic
poison is capable of giving rise to nerve disorder independently of
the production of organic disease. The analogy of gouty and rheu-
matic disease would lead us to an afiirmative opinion. Dr. Williams, of
Swansea, in a most noteworthy paper,' has brought forward evidence,
showing that "one invasion uf constitutional syphilis establishes a
diathesis .... which may manifest itself in the system of the affected
person for at least very many years afterwards. Under an apparent

1 "Brit. Med. J.," April 12, 1862.

SYPHILITIC AND RHEUMATIC NERVE AFFECTIONS. 311

absence of all disease the subtle taint exists, though veiled and con-
cealed by the deceptive garb of health, and may be communicated
by the parent to the child." A diathesis he defines to be "a latent
vital power which is capable of imparting a special direction to all
morbid processes which may occur in the body during the period of
its prevalence." He relates a case of severe bronchitis, one of pneu-
monia, one of apparent softening of the brain, and one of epilepsy,
which were rapidly cured by remedies solely anti-syphilitic. I am
strongly inclined to accept the above view, confirmed as it is by
the analogies of malarious and rheumatic disease, which seem to
modify other supervening disorders much in the same way as syphilis
does. I am more and more disposed to think that the conception
of a diathesis is a most important one, and that it must replace to
some extent that of a poison, or " materies morbi," which has been
carried much to far. Diday' holds that while secondary syphilis
belongs to the class of virulent, i. e., toxic, affections, tertiary belongs
to that of diathesis, like some skin diseases and rheumatism. In-
dividuals of feeble constitution are most liable to this unfavourable
change of an intoxication into a diathesis, which renders the morbid
phenomena much more inveterate. According to Williams's and
Diday's views, it seems quite possible that neuralgia in any of its
manifold haunts, or any other nerve disorder, might be aufond of
syphilitic character, and most successfully treated with anti-syphilitic
remedies. The following quotations from the work of a recent
French writer go to confirm the above anticipation.

M. Zambaco relates three cases, which prove, he says, in the most
incontestable manner that the syphilitic diathesis may attack the ner-
vous centres, and produce profound dynamic disorders, without our
being able to refer these disorders to a modification of structure; and
this too even when there exists complete paralysis of motion and sen-
sation. He quotes Gibert, Robert Melchior, and Follin as holding
the same opinion. In the first case a male, set. 28, who had shortly
before been cured of a double syphilitic sarcocele, died after having
suffered about a month with almost complete paraplegia and impaired
sensation of the lower limbs with paralysis of the sphincters. At
the post-mortem the cord was found healthy, the lungs contained in-
cipient metastatic abscesses. In the second case there was also almost
complete paraplegia, but no loss of sensation. The patient, a male,
set. 68, presented a cicatrix on the penis and a well-marked syphi-
litic lichen within a month of his death. All the organs were quite
sound. In the third case a chancre had existed six months before
the patient came under observation suffering from an impetigo and
an obstinate continual vague pain without precise seat, but felt
deeply in the brain. This pain increased, and at the end of a month
he was affected with incomplete right-side hemiplegia. Some days
later the paralysis became complete and speech w^as lost, but not

1 "Edin. Med. J.," April, 1882.

312 SYPHILITIC AND RHEUMATIC NERVE AFFECTIONS.

consciousness. The next day the feces and urine were passed in-
voluntarily, the right arm was contracted, the left leg affected with
subsultus, the tongue bitten by the teeth closed in trismus. Still no
loss of consciousness or sensation. Violent contraction of the limbs
ensued followed by coma and death. The brain and the cord were
carefully examined and found healthy. A case is related of quo-
tidian fever recurring daily at 5 P. M., which resisted quinine, but
was cured by mercurials speedily. The patient, a female, had a
papular eruption, but no very marked syphilitic symptoms. Two
other cases are recorded of a similar kind, but in which the presence
of syphilis was clearly evidenced. M. Zambaco believes that the
disorders above described result from a perturbation of the nervous
system under the influence of the syphilitic infection. Hysterical
attacks of a well-marked kind not only coincide with the development
of constitutional syphilis, but are cured by a specific treatment.
Three cases of this kind are related in which the patient had been
free from any hysteric affection before syphilitic disease appeared.
It is worthy of remark that the attacks of nervous disorder were in
all of them nocturnal, conforming in this respect to the ordinary
pains of syphilis. In one instance obscure nervous symptoms con-
tinued for more than a year, until the discovery of syphilitic ec-
thyma declared the nature of the disease, and led to its speedy cure.
Zambaco relates various cases of syphilitic neuralgia, many of them
cured by specific treatment, but he does not decide positively
whether these always depend on some actual lesion or not. Gjor^ re-
lates the case of a male, set. 40, who three years before his death
had marked symptoms of syphilis, and for the last four months
paraplegia, which was at one time complete, but improved to some
extent before his disease from phthisis. The cord was found per-
fectly healthy with the exception of some congestion of the veins of
the pia mater at its lower part. There was nothing else except the
usual changes in phthisis. In a second case, a female set. 31, had
had syphilis for at least five years, and died five months later com-
pletely paralyzed in all her limbs. The palsy commenced about 1^
year before death, affected first the right side, and three months
afterwards the left. It was attended with violent pains and spas-
modic contractions of the limbs. Sensibility was diminished in the
lower half of the body. The brain and spinal cord were perfectly
normal. The lungs were congested posteriorly. Nothing else mor-
bid. A third case is referred to in a Danish journal of the same
kind.

In connection with the influence of syphilis on the nervous system
I wish to make some reference to that of obscurely-developed rheu-
matism of a chronic kind. In the cases I have observed it seems to
me rather doubtful what was the exact nature of the morbid action,
but it was almost certainly either syphilitic or rheumatic, and as

' Schmidt's "Jabrb.," vol. ci. p. 299.

SYPHILITIC AND RHEUMATIC NERVE AFFECTIONS. 313

there were no traces of the former I am diposed to assume that the
latter disease was operative.

No. 182.— R. G. P., ffit. 40, m., ad. May 21st. Ill eighteen months; had
a fit at first in which he seemed strangled, but did not struggle ; for seven
mouths after was very dull and silent, then went to work and continued at
it till the last three months, but was not the same as before. The last three
weeks he has been troublesome, has various delusions, has no power over
the sphincters. On being asked, he says that he has pain all over the heacl.
Sleeps very badly. Head hottish. Urine clear, non-albuminous. P.
steady, natural. B. open. Pupils equal. No paralysis. No eruption.
Denies syphilis ; no traces of buboes or chancres. Used to suffer from rheu-
matism all about him. His treatment consisted of pot. iod. given for the
first ten days at the rate of gr. vij ter die, and for the rest of the time at
the rate of gr. x ter die, combined during the last month with tr. cinchon.
Henbane was also given as a nightly sedative, gr. x of the extract o. n.
This was replaced afterwards by extr. belladon. gr. J. By June 8th he was,
according to his wife's report, wonderfully altered for the better ; he had
more control over the sphincters. In fourteen days more he had become
quite sensible and had gone to work. While awake he had tolerable con-
trol over the bladder, but at night there was much incontinence. My last
report of him was on Aug. 3d, when he was at work and improving. Two
or three weeks before he bad a suppurating gland in the left axilla, but no
cause of irritation existed in the range of the lymphatics.

No. 188.— W. D., set. 43, carpenter, ad. July 3d, 1853. Subject to rheu-
matism about seven years, has had none for nearly twelve months. Is suffer-
ing as at present two months. His illness commenced with pain about
umbilicus, followed by vomiting, which has continued about fourteen days ;
he keeps no food on his stomach. The pain extends over his chest and
through to the back ; it is increased by food, and is relieved by vomiting.
Is seldom thirsty. Has little appetite. No epigastric tenderness. Pulse
natural. Skin cool. Sleeps well. Bowels costive. Urine clear and free
Some slight thickening of skin, and desquamation over knuckles. Ordered
pot. iod. gr. iij + ammon. muriat. gr. xv + vini colch. ttlv + tr. opii itLiv
-f inf gent. co. ^j ter die. He improved at once ; at the end of l4 days
his appetite was very good indeed. He had no sickness, and his food
digested well. July 31st. He is apparently well, but if he omits the medi-
cine his appetite is not so good. I did not see him again until Jan. 19th,
1856, when he stated that he had been suffering two months with great
pain in the left arm and between the shoulders. His stomach was all right.
The pain was felt much about the insertion of the deltoid. It was very bad
at night, compelling him to quit his bed and bathe his arm with warm water.
He was treated with pot. iod. gr. iij — iv -f dec. cinch. §j t. d. and linim.
tereb. c. opio to the arm. By Feb. 2d he was very much better, had re-
sumed work, slept till 7 A. M., and had only then a little pain. The medi-
cine was continued with tr. cinch. When I saw him again June 13th,
1856, he was an in-patient. He stated that he had been taken ill in March
with stiff neck, and the disorder proceeded over his head to the forehead,
where it caused pain and aching of the eyes. He had double vision when
he used both eyes except for a short time in the morning. The vision of
the right was better than that of the left eye. If he shut one eye he could
see objects close to him pretty well, but with both eyes they appeared misty.

21

314 SYPHILITIC AND RHEUMATIC NERVE AFFECTIONS.

This had been the case fourteen days. Had sharp pain in frontal region.
No distortion of face or of tongue. During the last month he had not been
able to use his left arm and leg, could move them now pretty well, but had
a numbed sensation all down left side. In the fingers of right hand he had
the same sensation, but had perfect use of that side. He had had no fit nor
loss of consciousness. He had been at work for fourteen days after I last
saw him, had been exposed to cold winds which brought on a relapse. By
July 11th he had lost the sense of sti0"ness in the left side, the leg was well,
but the hand was still lame and the vision double. He was treated with
pot. iod. gr. iij. Aug. 16th, he became again an out-patient under my care.
During the last week marked ptosis had ensued of the right eyelid, the pupil
had become dilated and the sight of the eye was now worse than that of the
left, which had previously been the weaker, but now was seeing fairly well.
Both eyes appeared normal. There was throbbing pain in the right temple
and across the forehead. Still has pain in left deltoid. Mouth rather drawn
to right. No tenderness of scalp. Not much strength in left hand or arm.
He took pot. iod. + tr. cinch, -f- sod. carb. + tr. nucis vomic. ter die till
Sept. 17th, the left hand became a good deal stronger so that he could grasp
fairly well, but the right pupil remained dilated, there was paralysis of the
internal rectus, and the ptosis continued ; the sight, however, was not much
affected. I have not seen him since.

Remarks. — It is I think certain that there were none of the ordinary
signs of syphilis in this man, though I have no statement in my notes to
that effect. Had any existed, they would certainly have been noticed during
some of the many opportunities I had of seeing him. The affection was
more like a shifting rheumatism than any other. Its location was first in the
stomach, then in the left shoulder, then at the base of the brain, involving pro-
bably also the basal cerebral ganglia. Perhaps the disorder of the eyes was
to some extent peripheral, the misty vision may have been produced by de-
ranged accommodation. Iodide of potassium was of most marked benefit,
but did not prevent relapses. It is tolerably certain that the head affection
did not depend on any organic disease, and I think it very questionable
whether there was any inflammatory action at all. In the first case the
cerebral hemispheres and the mesocephale seem to have been most affected ;
the paralysis of the sphincters depended I conceive on a morbid inhibitory
influence transmitted from the brain to the lumbar swelling of the cord.
There is one reason which weighs with me to some extent to regard those
cases as of rheumatic rather than of syphilitic origin, seeing that there were
no clear indications of the latter, which is, that ordinarily nerve disorder
seems to be much more a component element of rheumatism than of syphilis.
The great tendency of the latter is to cause the deposition of a low form of
exudation matter in nearly every tissue of the body, as Dr. Wilks well ob-
serves. Its affinities are decidedly with structural lesions, those of rheu-
matism with neuroses.

No. 184. — C. S., ast. 28, policeman, ad. April 7th. Ill two years. Has
pain at lower part of back extending round left abdomen, sacral region of
spine rather tender. Has seizures of tottering and weakness at times. Has
much nervousness and excitement of left side, which passes away with flatus,
after which he is much relieved. Has a large patch at the outer side of
thigh which is numb, but that has been so for years, ever since he laid on
damp ground. No sexual abuse. Has much walking which brings on the
pain. Had rheumatic fever four years ago badly, and has never been quite

EEMEDIES. 315

well since. He improved to some extent with pot. iod. + tr. cincLon., but
much more decidedly with citrate of quinine and iron + tr. nucis vom.
The numbness of the thigh diminished materially. He was under treatment
five months. It appeared to me in this instance that there was certainly some
affection of the cord itself of a rheumatoid or paretic character, and which I
should compare to a rheumatic neuralgia. The disorder was certainly not
mere lumbago.

CHAPTER XXXIX.

REMEDIES.

Some remarks on the action of the chief remedies employed in
the diseases we have considered may be of advantage.

Quinine asserts its especial influence as a nervine by its power of
controlling and curing neuralgia, not only malarious, but also when
produced by influenza or mere debility. This proves that it has a
special relation to the nervous system. Its power over malarious fever
is explicable on the same view, it checks and arrests the paroxysms
by virtue of its toning influence on the cerebro-spinal and sympathetic
systems. That it is no antidote in the sense of chemically neutral-
izing the malarious poison, is quite certain, as it may be given to
any amount in cases of visceral disease from this cause without the
least curative eifect ; and as it often quite fails to eradicate the mor-
bid influence from the system, as shown by the return of the dis-
order at spring and autumn or after exposure to trivial exciting
causes, although the individual has long removed from a malarious
locality. The peculiar eff"ects which quinine produces when given
in full doses, as buzzing in the ears, deafness, blindness, weakening
of the pulse, can all be accounted for on the view that it tones and
excites vaso-motor nerves to such a degree that the arteries of the
ears, eyes, and heart become contracted, and the parts they supply
ansemic. Its over-action in this way may be decidedly injurious.
In one case it caused a distressing constriction of the throat, and in
another a sense of fear about the heart. That the remedy is not
merely an anti-periodic, as some call it, seems to me abundantly
proved. There can be no question that it does actually increase and
invigorate the general nerve power when given judiciously, both re-
storing it when depressed by debilitating disease, and enabling it as
a prophylactic to resist morbid influences. The protecting power
of quinine in preserving men in health who are exposed to malaria
has been sufiiciently demonstrated. The inference from all this is
that quinine is likely to prove useful in all cases where nerve power
is much debilitated, more especially when the vasomotor system is
especially at fault, and where in consequence fevers, congestions, or

316 KEMEDIES.

asthenic effusions take place. Thus in pneumonia of a low type
where the lungs are gorged with blood, in asthenic rheumatic fever,
in some cases of typhoid and typhus fever, in chronic relaxation of
the uterus attended with menorrhagia and leucorrhoea, in bron-
chorrhcea, and in a multitude of analogous conditions where vascular
atony is marked quinine may be given with the distinct view of
toning and contracting 'the minute arteries and so arresting hyper-
33mia and exudation, while at the same time it elevates the power
of the cerebro-spina] system. Its use in various states of debility
is in a measure limited by its tendency already mentioned to cause
contraction of arteries to an undue extent so that the functional
energy of the heart and other important organs may be notably im-
paired from defective supply of blood. This, however, is most to
be feared when there exists considerable hypersesthesia. Like all
remedies of this class, quinine has the disadvantage of being liable to
act as an irritant to the various tissues, so that in inflammatory dis-
orders it is often a matter of great doubt whether it can be employed
without risk of doing harm. Much, however, may be done in many
instances to obtain toleration of the remedy either by giving it in
small doses, or by exhibiting it in combination with some modifying
agent. Thus Dr. Morehead^ finds the administration of quinine to-
gether with small doses of antimony to produce excellent results in
pneumonia both primary and attendant upon malarious fever. It
also acts very well in certain cases when given along with a small
quantity of calomel or blue pill. It is by no means necessary that
the tongue should be clean before quinine is exhibited, but it is
always desirable, often essential, that there should be no visceral
congestion. Great mischief may be done by pushing quinine with-
out giving heed to this precaution.

Arsenic is in many respects a similar remedy to quinine, and has
besides some peculiar actions of its own, which are significant of its
general modus operandi. It stands next to quinine in its power of
controlling malarious fever and neuralgia. It has a very marked
efficacy in preventing the recurrence of menorrhagia, more so indeed
than any other remedy with which I am acquainted. It arrests the
exudation of eczema, impetigo, and pemphigus when these eruptions
are not of an acute and sthenic character, i. e., where the tissues
are not very easily irritated. If the reverse is the case, arsenic will
surely aggravate the disorder. It has a considerable effect in still-
ing the jactitations of chorea, and acts in a somewhat similar way
in diminishing the tendency to recurrence of asthmatic bronchial
spasm. Mr. Hunt mentions that small doses of arsenic are of emi-
nent utility in checking chronic diarrhoea, or gastric irritation,
although the opposite effect is apt to ensue when the medicine is
given under different conditions. Mr. Spender mentions a very
confirmative instance. V. Brit. Med. J., Jan. 16th, 1864. The

' " Dis. of India," vol. ii. p. 370.

REMEDIES. 317

•following is to the same eifect. A healthy female, set. 25, while
suckling took by mistake two nixxx doses of Fowler's solution, in
consequence of which her breasts became pefectly dry. After the
medicine was omitted the milk returned abundantly. The same seems
to hold good of its action in conjunctivitis. Here we cannot but
observe a remarkable agreement between its action on the internal
and external tegument. The reading of these various facts seems
tolerably easy; it seems clear enough that arsenic given either in too
large doses, or in irritable conditions of the system, acts as a tissue
irritant, inflaming the skin and mucous membranes, and perhaps
other parts. On the other hand, it is evidently a nervine tonic, act-
ing on both departments of the nervous system ; increasing their
vital power, and enabling them to resist morbific influences. Its
action on the vaso-motor nerves, especially those of the cutaneous
and uterine vessels, is very marked, efl"ecting the contraction of the
arteries supplying these parts, so that hypersemia is diminished, and
serous and sanguineous discharges are arrested. The French com-
mission report that arsenic is a most powerful febrifuge, and has
unquestionably the property of reducing engorgements of the spleen.
This latter action (like the former) must surely be ascribed to its
tonic influence on the nerves of the splenic artery in consequence
of which the undue supply of blood to that organ will be reduced to
more nearly its normal amount. The curative action of arsenic in
chorea and asthma may be explained in a like way by regarding it
as a tonic of nerves or nervous centres which are weak, unduly ex-
citable and mobile. In chorea the cerebro-spinal, in asthma the
vagi nerves feel its beneficial influence. Schmidt and Sturzwage^
have determined that small doses of arsenious acid produce a con-
siderable diminution of metamorphosis (20 to 40 per cent.). Both
the urea and the pulmonary COg were lessened, and corresponding
quantities of fat and albumen were retained in the body. I think it
will be admitted that the above exposition of the modus operandi of
arsenic is at least consistent with itself, and that the original assump-
tion explains naturally all the therapeutical facts with which we
have become acquainted empirically. It has the advantage of doing
away, as in the case of quinine, with any notion as to the specific
action of the remedy, and of reducing the various phenomena under
an intelligible and rational principle. The chief difference between
quinine and arsenic seems to lie in this, that the latter is much more
of a tissue irritant than the former, and has more special localities
for its operation. Dr. Hughlings Jackson has suggested to me that
the therapeutic virtue of arsenic may depend on its replacing phos-
phorus, or some other isomorphous constituent of nervous tissue
which has come to be deficient. This is not at all improbable, and
at any rate there can be no doubt that arsenic improves the nutri-
tion of the nervous system. In the administration of arsenic much

• " Parkes on the Urine," p. xxiii. .

318 REMEDIED.

may be done to adapt the remedy to the special state of the system.
Thus it may be given with a saline when there is a tendency to
inflammatory excitement, or with tr. cinchonse when depression and
weakness of circulation are prominent features. The addition of a
little opium is a useful guard to obviate intestinal irritation, and
should generally be made, when it is requisite to give rather large
doses, as is the case in ecz. figuratum, in malarious fever^ and some
instances of sciatica.

Iron requires merely a brief mention as a nervine tonic. The
saccharated carbonate, and citrate of quinine and iron are the most
useful forms. I have tried the corresponding hypophosphite, but it
does not seem to have any advantage. In cases where the urine is
acid and lateritious with accompanying fever and prostration, and
where it is doubtful whether quinine alone will be borne well, it often
answers to give citrate of quinine and iron with citric acid and bicar-
bonate of potash, so as to combine the tonic with an effervescing
saline to which also a few drops of hydrocyanic acid may be added.
The recent investigations of Pokrowsky^ show distinctly the chief
effect of iron to be manifested in improved nutrition, the animal
temperature being raised, the urea secretion augmented, and the
weight of the body increased. He states that all preparations of
iron act alike. I should qualify this by adding if they are equally
well digested hy the stomach. M. Cordier^ has recently adduced
evidence to show that lactate of iron interferes less with digestion
than any other chalybeate, even than " fer rdduit." This might be
important to remember in dealing with great anagmia associated with
irritability of the stomach, where the ordinary preparations of iron
cannot be tolerated.

Strychnia is a nervine tonic which addresses itself specially to
the motor-nervous apparatus of the cerebro-spinal system. It finds
its opportunity in all cases where the nerve cells of the centres are
weak, and cannot furnish the requisite stimulus to the motor nerves,
whereas, it is injurious in all conditions of an opposite kind. It is
not usually considered to have any action on the brain, but some
very positive evidence has convinced me that it affects the superior
as well as the spinal centres, arousing and increasing their nervous
energy when it is defective. On the sympathetic system it acts
much less evidently. Dr. Hannotte Vernon^ has, however, shown
that it powerfully stimulates the developed uterus to contraction in
states of inertia, and its power of arresting vomiting in certain cases
of irritability of the stomach is certainly very striking. It is occa-
sionally serviceable in torpor of the bowels as an addition to purga-
tives, and I have seen it remove very formidable symptoms of in-

' V. Chappie, "Med. T. and Gaz.," March 2d, 1861. Alm^s, " Gaz. de Paris,"
xxii., 1860.

2 Virchow's " Archiv." xxii. 5, 6 ; 1861.

3 "Edin. Med. J ," 1863.

4 "Brit. Med. J.," Dec. 1857.

REMEDIES. 319

testinal obstruction. Thalwitzer^ has found it an effectual remedy
in both tertian and quartan ague, preventing relapses much more
certainly than quinine. It should invariably be administered in
solution and not in the form of pill. Given in this way it is most
perfectly safe, and there is not the least risk of its producing the so-
called cumulative effects. I have given it very largely for many
years, and have never observed anything of the kind. Dr. Fleming's
explanation of apparent cumulative action is, I have no doubt, cor-
rect.^ He considers that a number of pills remain for a time undis-
solved in the alimentary canal, till some change suddenly occurs,
when they all liquefy and are absorbed at once. The view adopted
by Dr. Radcliffe that the action of strychnia depends on its lessen-
ing the capacity of blood for the absorption of oxygen I must con-
sider erroneous, as I cannot think that the tonic and energizing in-
fluence of the drug can be explained by the mere diminution of the
arterial character of the blood. That strychnia so affects the blood
may be very true, but I hold it to be a mere " neben werk" of its
action, and in no way essential to its therapeutic eflficacy. Semi-
cyanosis of the blood by other means does not increase nervous
energy.

Digitalis h'as long been employed and ranked as a depressant
agent, and that it may be used as such very effectively there is no
doubt. Latterly, however, various observers have satisfied them-
selves that it may under certain circumstances produce diametrically
opposite effects, acting in fact as a powerful cardiac toner or stimu-
lator. I stated my belief of this in 1859, v. Brit. Med. J"., Dec.
17th, and since then evidence has accumulated considerably proving
that such is the case. Winogradoff and Traube show by exact ex-
periment that digitalis if not given in excess does not diminish, but
actually increases the pressure in the arteries. The former states
that digitalis acts both on the regulating and motor nerves of the
heart (the vagi and sympathetic cardiac nerves), and that the degree
of pressure in the aortic system is the conjoint result of these two
factors. The first action of digitalis on each is to excite, and the
second to paralyze. If then the motor are more stimulated than the
regulating nerves, the arterial pressure will be increased, and so it
"will be if the regulating are enfeebled while the motor are excited.
On the contrary, the arterial pressure diminishes when the regulating
nerves are more strongly excited than the motor. In a dog after
division of the vagi the pressure rose after injection of digitalis from
124 to 260, declining in ten minutes to 176 millim. Repetition of
the injection speedily arrested the heart's action. There seems to
be a remarkable correspondence between these observations and
those of Hufschmidt and Moleschott as to the effect of irritation of
the medulla oblongata and spinal cord on the frequency of the pulse,

1 "Preuss. Militar. Arztl. Ztg.," 1862.

2 "Edin. Med. J.," Dec. 1862.

320 REMEDIES.

V. p. 22. Tn addition to the results quoted there, it may be men-
tioned, that they found that irritation of the medulla oblongata was
conducted to the heart through the pneumogastric, and not through
the sympathetic nerves, while irritation of the spinal cord was trans-
mitted to the heart through both sets of nerves. From the above
evidence there seems good ground to conclude (1) that digitalis in
the milder degrees of its action has a stimulating influence upon the
heart, acting through the medulla oblongata and spinal cord or the
cardiac nerves proceeding from them ; (2) that its stronger action
has the reverse effect, like galvanism or mechanical irritation, arrest-
ing the heart's movements. How this arrest is produced is not clear.
On the one hand, it may be supposed that the over stimulus tetanizes
the heart, producing such strong contraction that the ventricles no
longer relax to admit blood, which of course would bring the cir-
culation to a standstill. This view is supported by the fact that
according to Dr. Fuller's observations and my own the heart after
death from digitalis is found with its cavities firmly contracted, con-
trasting remarkably with the condition produced by aconite and
chloroform. On the other hand, the arrest may be regarded as the
result of inhibitory action, the excessive stimulus producing a mor-
bid and depressing effect. This view is on the whole I think the
most probable, as we are frequently meeting with analogous instances
where it appears that an unnatural or unsuitable stimulation tends
to paralyze nervous power. Besides the amount of stimulus the
degree of excitability of the cardiac nervous and motor apparatus is
a highly important factor of the ultimate result. This is demon-
strated by the following quotation from Mr. Lister's most valuable
paper : " In a healthy state of the nervous system very gentle irrita-
tion of the vagus increases the heart's action, while a slightly stronger
application diminishes the frequency and force of its contractions

•. When partial exhaustion has occurred a much stronger

galvanic stimulus is required to produce the same effect upon the
heart than at the commencement of an experiment ; and thus an
action of the battery which when first applied causes marked diminu-
tion in the number of beats, may after a while come to have the
opposite effect, and increase the heart's action as decidedly as it had
previously lowered it; while at an intermediate period it may seem to
have no influence at all." Just in the same way, I conceive, digi-
talis tones and strengthens the action of a feeble heart, but lowers
that of a vigorous one.

Clinical observation in various particulars confirms the above views.
Thus there is some evidence that digitalis acts in a like way upon
the vessels as upon the heart. It is said to check epistaxis, and
Dr. Brinton affirms it to be the best remedy for hemorrhage from
pulmonary cavities in doses of ^.SO to 90 6tis vel 4:tis horis. In the
case of monorrhagia it is considered to act on the uterine tissue
rather than on the vessels, but this seems to me problematical, see-
ing that the muscular fibres in the unimpregnated state are unde-

REMEDIES. 321

veloped. However this be, it is certain that it produces contraction
of contractile tissue. Digitalis is spoken of highly by some observers
for its efficacy in neuralgia. Mr. Hardwicke* has always used it in
" tic douloureux," with the happiest results, giving gr. | of the pow-
der every three hours even in cases where he much feared its de-
pressing effects on account of the great debility. M. Serre^ reports
the cure of several long-standing cases of hemicrania including his
own of fifteen years' duration by means of Debout's pills; consisting
of quin. gr. iss -|- pulv. digitalis gr, | in each, one taken every
night for three months. The quantity of quinine is too small to
produce any material effect. Boison' says that a pill of musk gr. j
+ extr. digitalis gr. iss -h opii gr. ^ has a magical effect upon neu-
ralgia. There can be no doubt that the drug acts in such instances
in the way of a tonic, probably much like the quinine with which it
is associated, and which has in large doses a like power of slowing
the heart's action. The advantage of giving large doses of digitalis
in cases of delirium tremens seems to me sufficiently proved, and I
think it nearly as certain that it is only the asthenic variety of the
disease which is capable of being thus benefited. If further observa-
tion establish this point it will be an additional evidence in favour
of the primary tonic action of the remedy, and will accord with what
■we have just seen of its curative influence in neuralgia. Dr. Wilks^
has performed a most interesting crucial experiment which absolutely
proves that digitalis may revive and restore the failing action of the
heart, and therefore cannot possibly be a mei-e depressant. The
patient was a woman, who having long suffered from disease of the
heart had a severe flooding after labour. She was apparently in
articulo mortis, her limbs were cold, face livid, no pulse at the wrist,
and a mere fluttering to be heard when the ear was applied to the
region of the heart. The body was covered with a deathly clammy
sweat. Brandy and ether had failed, but 5ss doses of tr. digitalis,
0. hora, restored her after seven had been given, and she recovered.
I had for some time intended to use the same means if a fitting
opportunity occurred, and had spoken of the same to several of my
friends as a possible succour in extremis. Two cases which I re-
corded, V. Med. T. and G-az., Dec. 13th, 1862, of the tonic and
restorative action of digitalis in debilitating disease of the heart are
worth referring to by any one who has doubts on the matter. The
diuretic power of digitalis is not unfrequently very evident, but it
partakes of the family infirmity belonging to all its congeners, that
it is very uncertain. Dr. Christison^ is inclined to believe that its
two actions, the diuretic and sedative, are incompatible. I think
this is very likely, and further that in any case where it acted princi-

> "Assoc. Med. J.," June 1, 1855

2 "Bull, de Therap.," April 15th, 1861.

3 "Bullet, de la Soc. de Med. de Gent.," May and June, 1861.
" "Med. T. and Gaz.," Jan. 16th, 1864.

6 "Ediu. Monthly J. of Med.," Jan. 1855.

322 REMEDIES.

pally on the heart as a toner or sedative its renal action would be
less developed. Dr. Christison speaks very decidedly as to the non-
increase of renal irritation in the cases where he has administered it
for the relief of the dropsy of Bright's disease.

Tannin may be taken as representative of the class of astringents.
It seems to me certainly doubtful whether it has any direct action
on nervous tissue, while that it exerts such on the smaller vessels is
tolerably certain. It probably renders their membrane more firm
and resistant, and therefore less distensible by the blood and perme-
able by exudation. It finds its opportunity in asthenic forms of in-
flammation and congestion, where it reduces the hypersemia by con-
tracting the vessels, shrinking up and obliterating those which have
been morbidly developed. In a case of inveterately relapsing cor-
neitis of both eyes producing very great impairment of sight, I ulti-
mately obtained complete recovery by giving gr. xxx of tannin ter
die. I think it is quite possible that the nervous tissue may be
affected by the astringent in an analogous way to the vascular, ren-
dered less mobile and excitable. The beneficial effect of alum in
lead colic, which can hardly depend on removal of the lead from the
system, points to some influence of this kind. In any condition
where nervous disorder might be increased or maintained by hyper-
semia tannin would probably be useful. On this ground its utility
may be explained in some cases of epilepsy. Its chief advantage in
such and in similar disorders depends on its having less tendency to
cause irritation than most other tonics.

Sulphuric and Nitric Acids have certainly some claim to be re-
garded as toners of vaso-motor nerves. They cannot be supposed of
course to act in their original form on the parts they influence, as
their acid quality must be lost the moment they enter the circulation.
They cannot be mere astringents like tannin. When sulphuric acid
restrains a choleraic purging, or a colliquative sweating, these effects
must surely be produced through the nerves that regulate the arteries
of the internal and the external teguments. Its special nervine
action is attested by the following quotation from Dr. Pereira •} " No
remedy is so successful in relieving the distressing itching, formi-
cation, and tingling of the skin as diluted sulphuric acid taken in-
ternally." Nitric acid is certainly a remedy of considerable efficacy
in catarrhal affections both of the bronchi and intestines, and it has
further this special indication of its nervine operation that it is often
very serviceable in the spasmodic period of pertussis. To those who
are impressed like myself with the great concernment of the nervous
system in all cases of malarial fever, it will not be without signifi-
cance that nitric acid has been found a valuable remedy, in these
disorders, in some cases surpassing quinine.^ It is very useful also
in enlarged spleen.

' "Mat. Med," vol. i. p. 472.

2 "Amer. J. of Med. Sc," April, 1861— Jan. 1860.

REMEDIES. • 323

Opium is a drug the empirical use of which very far outruns our
scientific knowledge of its action. Moliere's quiz at physicians on
this score is almost as appropriate now as at the time he wrote.
There can, I think, be scarcely a more glaring instance of the neces-
sity which exists for careful research into the modus operandi of
remedies. Taking our common experience of the eifects of opium,
we know that it acts as a soporific, as a calmer of pain, and as an
arrester of intestinal and other secretions and morbid profluvia, even
of some hemorrhages. Graves gives a case in which obstinate bleed-
ing from the gums was arrested by opium, v. Clin, Med., p. 272.
Stewart relates some cases in which opium was given in very large
doses to females who were syncopic, and almost dying from uterine
hemorrhage with very great advantage, v. Med.-Chir. Trans., vol.
iv. p. 366. Further we know that in certain constitutions it has a
stimulating influence on the brain, manifested both in greater activity
of the intellectual functions, and in a greater capacity of enduring
fatigue. This stimulating eifect when excessive may be succeeded by
depression and sopor. In some inflammatory diseases, as in sclerotitis
and peritonitis, opium decidedly checks and subdues the hypersemia
and tendency to exudation. The action of the drug on the cutaneous
nerves seems to be rather uncertain, it does not seem by any means
to cause diaphoresis frequently. Nay, even Dover's powder I have
found in accordance with Deschamps'' recommendation materially
to check the night-sweats of phthisis. The reading of these various
facts is sufficiently obscure; it is not easy to refer them to any one
general principle. Perhaps it is premature to make the attempt in
default of accurate observations upon animals, yet as they are not
by any means aff'ected by the drug in the same degree in which
human beings are, we cannot avail ourselves to any great extent of
this mode of inquiry. Muller indeed has shown^ that opium exerts
a local influence on the nerves, destroying their excitability, and that
this influence is not propagated either towards the periphery or cen-
tre. This is true both of the cerebro-spinal and sympathetic nerves.
It may be questioned how far such a proceeding as immersing a
nerve dissected out from the tissues in a solution of opium fairly
represents the action of the drug when it is diff"used through the
whole mass of the circulating blood. However, if we accept the
above experiments of Muller, it seems reasonable to refer the sopo-
rific and pain-allaying property of opium to a sedative action exerted
on the nerves or nervous centres. On this view we should expect
that the nerves generally would be similarly affected, that the face
would be flushed in opium poisoning, that hemorrhages and inflam-
mations would be aggravated, and diarrhoeal and other fluxes in-
creased in consequence of paralysis of the vaso-motor nerves of the
facial, intestinal, and other arteries. As the reverse is the case we

> "Gaz. Med. de Lyons." Jan. 1861.
2 MuUer's "Physiol.," vol. i. p. 679. ■

324 * REMEDIES.

meet with a difBcultj, wbich we must try to remove. It can scarcely
be supposed that opium acts in a contrary way on the sympathetic
to that in which it does on the brain and cord. It stills pain alike
in parts supplied by either set of nerves. It might be imagined
that opium acted on other tissues in an analogous way to that in
which it affects the nervous, rendering them as it were torpid, and
disinclined, or inapt to function. This would explain the arrest of
secretions, and perhaps of exudations, and of inflammations, but
leaves quite unaccounted for, or rather is contradicted by, the stim-
ulant action of opium on the brain, its power of preventing fatigue,
and of arresting hemorrhages. Two things are most necessary to be
regarded in speculating on the modus operandi of opium, viz., the
amount of the dose, and the individual idiosyncrasy, or the state of
nervous power. According as these vary its effects vary extremely.
It appears that the larger the dose, eceteris paribus, the more
speedily and decidedly sopor ensues, while small doses are more
apt to cause excitement. Small doses also are quite adequate
to control diarrhoeal exudations and to "lock-up" secretions. It
may be supposed, it appears to me, with much probability that the
apparently different actions of opium depend very much on the cir-
cumstances whether it acts chiefly on the cerebro-spinal or sympa-
thetic systems, a difference which may reasonably be ascribed to
original diversities of constitution. The chief action of opium in
moderate doses is that of a stimulant or toner to nervous tissues,
but in the majority of individuals it acts more on the sympathetic
than on the cerebro-spinal system. By stimulating the vaso-motor
nerves it produces contraction of arteries, and thus lessens the flow
of blood to various parts. Hence the skin of the face and head in
opium narcosis becomes pale and cool, while the brain more or less
deprived of blood lapses into sopor. Hence also hypergemias,
hemorrhages, and morbid exudations are arrested, and even natu-
ral secretions restrained. These instances seem to me almost con-
clusive ; if opium did not contract arteries how could it arrest a
uterine hemorrhage ? The calming of pain by the local application
of opium, as in subcutaneous injection, may be explained according
to the view I adopt if we bear in mind what has been advanced as
to the essential character of neuralgic pain for the relief of which
opium is most efficacious. The suffering nerves being in a state of
vital debility are restored to a healthier state by the action of a
stimulant. I have seen the subcutaneous injection of morphia pro-
duce immediately a good-sized patch of redness with two or three
red elevations like longish wheals. Mr. Simon says, " Opium is not
an anaesthetic except by the production of stupor." The mental
excitement and the prevention of fatigue may be accounted for by
its exerting a stimulant action on the brain and spinal cord. The
chief objection to the above view is that opium if it acts specially on
vaso-motor sympathetic nerves ought to dilate rather than contract
the pupil. The radiating fibres of the iris, which are made to con-

REMEDIES. 325

tract by galvanizing the cervical sympathetic, ought to be similarly
Effected when opium is administered. It is very possible that this
would be the case ,did not the motor nerves of the circular fibres
pass through, and probably receive additional fibres in the lenticular
ganglion. This nervous centre must be regarded as belonging to
the sympathetic, and consequently the nerves proceeding from it will
be affected by opium in the same way as other sympathetic nerves
are. The pupil is therefore contracted. Unless it be admitted that
the gray matter of the ciliary ganglion influences the nerves which
proceed from it, it is not easy to imagine what can be its purpose.
If the action of opium could be limited like galvanism to the sym-
pathetic filament proceeding to the nasal, or to the lenticular ganglion,
it might produce dilatation. As it is, however, the far more power-
ful muscular and nervous apparatus which effects the closure of the
pupil overrules the other. A case recorded by Dr. Baly in his trans-
lation of Muller's Physiology, vol. i. p. 828, may be noticed here.
The third nerve of one eye was paralyzed, the pupil was slightly
dilated and perfectly fixed, the strongest light causing no contraction,
although the vision was perfect. The adjusting power of the eye
was lost or much impaired. Now in this case the pupil was not
much dilated because the gray matter of the lenticular ganglion still
kept up an influence on the motor nerves, but the iris could not be
influenced through the retina, because the communication of the
ganglion with the third nerve was interrupted. Belladonna, on the
other hand, dilated the pupil further by paralyzing the ciliary gan-
glion. There is no doubt that the optic and the third nerve constitute
the nervous apparatus essential to the main movements of the iris,
and the dilatation can be accounted for under ordinary circum-
stances simply by the unopposed action of the straight fibres, most
of which may be merely elastic tissue. The sympathetic fibres are
probably as in other situations chiefly distributed to vessels, and take
no important part in the movements of this muscular curtain. Clearly
full dilatation of the pupil occurs under circumstances which seem
to exclude all stimulation of any nerve, as in chloroform, narcosis,
and fatal syncope.

A second objection which may be made is that copious sweating
occasionally occurs in opium poisoning, and even from moderate
doses of the drug. This looks more like relaxation of vessels than
contraction. To this it may be replied, that copious sweating is a
common result of any cause which powerfully depresses the nervous
system ; it occurs in apoplexy, in profound debility of malarious
origin, and in sudden embolism of the pulmonary artery. It may
therefore well occur in fatal opium narcosis, where the brain is para-
lyzed for lack of arterial blood. As to the diaphoretic action of
ordinary doses it may be explained on the following grounds. All
glands, as Bernard shows, have their motor nerves, stimulation of
which excites them to active function. Now retaining the view that
the primary action of opium is stimulant, it is quite conceivable thac
22

326 REMEDIES.

in some parts it may stimulate the gland-motor moi'e than the vaso-
motor nerves, and thus promote instead of suppressing secretion.*
Individual peculiarity is probably largely concerned here ; thus cats
are, I believe, invariably profusely salivated by a dose of opium,
while I scarcely have ever heard of such an occurrence in man ex-
cept the case mentioned by Pereira.^ A third objection may be
raised from the circumstances that opium produces in some persons
an increased flow of urine, as especially observed by Dr. Woodward.^
I have several times observed this, but have always seen that the
secretion was pale and aqueous just like hysterical urine. It is very
difficult to say what condition of vessels coexists with this kind of
renal secretion, but I doubt very much whether it is one of arterial
dilatation. Most probably some peculiar change is produced in the
homogeneous membrane of the Malpighian capillaries, affecting their
filtering action. The slower and diminished breathing observed in
opium narcosis depends probably on a state of torpor of the respira-
tory centre, itself the result of a diminished flow of arterial blood.
The same condition of the hemispheres accounts for the coma, the
brain being, as lately shown by Durham^ and Bedford Brown, ^ more
or less ansemic during sleep. The occasional occurrence of con-
vulsions may with our present knowledge be reasonably ascribed to
the cerebral anaemia. That these various phenomena depend princi-
pally on arterial contraction seems to me still more probable from
the remarkable restorative efi'ect of belladonna, which has now been
observed in several cases.^ If the vital power of the tissues them-
selves was deeply injured by the one drug, they could hardly so soon
resume their action under the influence of the other. In one re-
corded case, v. Brit, and For. Med.-Chir. Rev., April, 1858, the
pulse was scarcely perceptible, though the heart's beat was strong.
In another mentioned by Dr. J. W. Ogle, Med. T. and G-., Oct. 3,
1863, the surface was icy cold. Both these phenomena are mostly
results of over-excitement of vaso-motor nerves. While I cannot but
attribute the chief part of the operation of opium to its influence on
the vaso-motor nerves, I think also that it may in large doses (like
alcohol) act paralyzingly by over-stimulus on the encephalic nervous
centres. Indeed both agents have in many respects the same eff"ects.
Thus both in small or moderate doses stimulate the brain, in larger
produce sopor but leave the respiratory centre efficient, and in still
larger doses cause fatal coma and collapse. In all cases a very
great deal depends on the degree of impressionability of the nervous
force, and on its condition in different parts. If the vaso-motor
nervous apparatus be very sensitive, as in young children, the arteries
are very readily occluded, and coma ensues, while in older persons
the gray matter of the hemispheres will be first affected in a way of

1 "Mat. Merl.," vol. i p 708.

2 "Boston Med. J.," vol. Isv. p. 108.

3 "Guy's Hosp. Reports," vol. vi. p. 149.
« "Amer. J. of Med. Sc," Oct. 1860.

6 Ibid., Jan. 1852.

REMEDIES. 327

excitement, and it •will require a large dose to produce a soporous
state. In states of cerebral excitement it may require an almost
poisonous dose of the narcotic to produce sleep. The action of the
heart is commonly increased by moderate doses of opium, or at least
in nowise depressed, but after poisonous doses it becomes very
feeble and failing. This results partly from the contraction of the
coronary arteries admitting an insufficient supply of blood to the
muscular tissue, and partly from the same state of the bloodvessels
of the cardiac centres, in consequence of which they cease to supply
the heart with nervous influence.

Belladonna may be ranked as the physiological opposite to opium.
In full doses it causes extreme flushing of the face and head with
great distension of the veins, numbness of the face, dimness of sight
or even blindness, confusion of head, delirium sometimes attended
with great excitement, dryness of the mouth and throat, extreme
dilatation of the pupils, and often an erythematous eruption. The
chief points of contrast in its action as compared with that of opium
are the state of the pupils, the deep flushing of the face, the delirious
excitement, the acceleration and sometimes increased strength of
the pulse, and the hurried breathing. Sopor is generally consecutive
to delirium, and is often replaced by wakefulness. Therie can be to
my mind but little question that the deep congestion of the skin of
the face and head, the delirium, and the cutaneous erythema depend
on arterial dilatation and increased afflux of blood in those parts.
In one case the skin of the face had been as red as blood, but had
quite returned to its natural state twenty-two hours later when I saw
the patient ; delirium had existed along with the congestion, and had
disappeared with it. It is impossible to consider such temporary
congestion as the result of tissue irritation, the effect of a mustard
poultice would not have ceased so speedily. The acceleration of the
pulse may reasonably be ascribed to paresis of the cardiac branches
of the vagi, or of the vaso-motor nerves of the coronary arteries, the
first being the more constant occurrence, and the second probably
being added, when the pulse is not only rapid, but strong. The
accelerated breathing is the result partly of free blood-flow through
the medulla oblongata, partly of the increased cardiac action. The
increased heat of the skin, the erythematous eruption, or the perspi-
ration, all which have been observed, are easily explicable on the
view of vaso-motor nerve paralysis. The evidence in favour of the
pain-calming action of belladonna is very decided. Trousseau does
not hesitate to affirm as the result of very numerous experiments
that of all the remedies employed against the symptom pain there is
none which seems more constantly efficacious than belladonna. He
admits, however, the superiority of opium in internal pains. The
blindness is probably in part dependent on paralysis of the ciliary
muscle which is afi"ected just in the same way as the iris, and through
the medium of the same nerves. The numbness of the face and the
weakening of muscular power are also indications of diminished vis-

828 REMEDIES.

nervosa. Botkin^ and Michea^ both agree that belladonna destroys
the excitability of the nerves, affecting the motor before the sensory,
and lastly the cerebral hemispheres. The peripheral extremities of
the nerves are first affected. The heart's action ' was rendered
■weaker and more frequent, and the pressure in the arteries dimin-
ished. Thus most of the phenomena produced by belladonna seem to
be satisfactorily explicable on the view of its occasioning paresis of
nervous tissue generally and especially of the vaso-motor nerves.
There are, however, two very constant results of its action which
seem to be of a different kind. These are the dryness of the mouth
and the throat and the dilatation of the pupil. The first seems to
imply a contraction of the vessels supplying the mucous membrane
and the salivary glands effected doubtless through stimulation of
their nerves. I have examined the throats of various persons under
the influence of atropine, but have not been able to satisfy myself
that there was any marked dryness. I am therefore much inclined
to regard the phenomenon in question more as a dyssesthesia than
as a real arrest of secretion. If, however, it actually occurs, it may
be explained on the view of its paralyzing the gland-motor nerves,
while opium sometimes does the contrary. The dysphagia and
aphonia which sometimes occur are certainly paralytic phenomena,
and so in accordance with the general mode of action. The question
as to the action of atropine on the pupil has been admirably studied
by Dr. Harley,^ who considers it proved, (1) that atropine does not
dilate the pupil by stimulating the sympathetic as galvanism does,
and (2) that it does not do so either merely by paralyzing the third
nerve, supplying the circular fibres of the iris. He is most inclined
to adopt Ludwig's view that the drug acts directly on the radiating
fibres, and relates an experiment showing that a recently removed
eye immersed in solution of atropine comes to have the pupil fully
dilated in some hours, while the companion eye placed in water shows
no such change. It is a very difficult question to decide completely,
but after a careful perusal of the facts recorded I think there is little
doubt that atropine does not stimulate the cervical sympathetic and
thus produce contraction of the radiating fibres of the iris. The
chief evidence is as follows: —

(1) Atropine applied for twenty-five minutes to the upper end of
the divided sympathetic does not cause the contracted pupil to dilate
as g;ilvanism does. (2) When the third nerve is divided the pupil
dilates immediately and permanently, and the dilatation is not in-
creased by atropine ; the cervical sympathetic being now divided,
the pupil contracted to one half, both sets of fibres being paralyzed.
(3) The pupil being fully dilated by atropine the sympathetic on that
side was divided, the ear became warm, but the pupil remained fully

* Virchow's "Archiv.," vol. xxiv. p. 83; 1862.

2 "Ann. de Therap.," 1864, p. 8.

3 -Edin. Mjd. J.," 1856, 1857, p. 431, and p. 705.

REMEDIES. 329

dilated for three days, afterwards gradually contracted, and was
completely so by the ninth day. (4) Sympathetic divided on one
side, the contracted pupil made to dilate at first to half its extent
with atropine, 'subsequently by long-continued application made to
dilate completely. The general bearing of these facts seems to me
to be that atropine does not stimulate the sympathetic, but that it
acts on it as it does on other nerves, paralyzing therefore the ciliary
ganglion and nerves, as well as the third. The effect of atropine on
the ciliary muscle should be taken into account. This, as having
but one set of fibres, is a simpler structure, and its action can more
easily be determined. Atropine certainly paralyzes it, and so also
does disease of the third nerve. It therefore seems probable that
atropine acts in a like manner upon the iris with which it is asso-
ciated. As to the direct action of atropine on the iris it seems diffi-
cult to understand how it can affect one set of fibres without the
other, the two being supplied absolutely by the same capillaries. It
is very possible that the contraction of the pupil produced by division
of the sympathetic depends on an increased flow of blood to the iris,
and on an exaltation of the vital properties of its circular fibres,
which then contract with greater energy, v. p. 27. When the
divided sympathetic is galvanized dilatation ensues because the vital
power of the constrictor is now diminished, and so it is less capable
of action. The radiating fibres meanwhile, though similarly affected,
meeting with less resistance shorten by mere passive contractility.
Paralysis of the sympathetic makes it more difficult for atropine to
dilate the pupil because of the increased energy of the constrictor, so
that a greater amount of the drug is required to overcome its action.
When l)ella donna applied to the skin of the forehead dilates the pupil
of that side only it is difficult to suppose that it is absorbed, or that
it directly aff"ects the ciliary nerves. What is certain is that it must
act on the sensory filaments of the ophthalmic division of the fifth,
and through these it is probable that a reflex action of an inhibitory
paralyzing character is communicated to the third nerve. ^ Botkin's
experiments seem sufficient to prove that it cannot act as a stimulant
as Wharton Jones and others think. I have examined the web of
the frog under the influence of atropine, both when applied locally
and injected subcutaneously, but I did not observe that the arteries
were notably affected. The circulation is very apt to be afi"ected by

• Tlie above had been written a long time before I met with the following passage in
Simon's Led. on Pathology, p. 219. " An aneesthetic agent operating on the pe-
ripheral expansion of the fifth nerve produces the negation of, excitement in its centre ;
this condition diffuses itself to the motional centre of the iris, and as excitement
would have shown itself in contraction of the pupil, so the opposite nervous condition
evinces itself in expansion of that aperture. Where the reactivity of the spinnl cord
is very highly excited a peripheral surface may by the influence of belladonna be ren-
dered incapable of provoking reflex movements. Thus, for instance, if a frog be ren-
dered tetanic by opium or .strychnine, any contact of its cutaneous surface will pro-
duce universal spasm ; if either before tliis poisoning, or subsequent to its manifes-
tations, one limb of the animal be plunged into a solution of belladonna, no mechanical
irritation of that portion of the body will cause the tetanic convulsion."

380 ■ REMEDIES.

movements of the animal which possibly may have been a cause of
error. The state of brain in which belladonna is occasionally useful-
as a soporific is where there is violent excitement and wakefulness,
with a contracted pupil.

Hyoscyamus appears to be chiefly a simple and direct cerebral
sedative. Of its calmative and hypnotic action I have no doubt,
but it produces no other distinct effect when given in ordinary doses.
In poisonous quantities it acts somewhat like belladonna. The nar-
cotic effect of both drugs is, I believe, due to direct action on the
nervous centres.

Aco7iite is certainly of great value as an external application in
cutaneous hypersesthesia, and in some neuralgias, but I am shy of
administering it internally. It may be used, however, in various
conditions characterized by sthenic nervous excitement, certain
pyrexise, neuralgias, and headaches, but its effect should be carefully
watched lest it induce perilous depression of the heart's action.
The dose at first should not exceed y\x of the tincture (PA. Brit.)
ter die.

Cannahis Indica has certainly an influence on the brain, producing
not unfrequently a kind of intoxication or delirium. There seem to
be great individual differences in respect to the tendency to be thus
affected. In most persons an ordinary dose produces no notable
effect, but in some the cerebral disturbance, and the delusions usually
of a pleasing kind are very considerable. The primary stimulant
action is succeeded after a time by a sedative, but no actual narcosis
appears to be produced. There is evidence that cannabis has a
tranquillizing influence on the spinal cord in tetanus, but it is not to
be relied on for producing this effect, and does not seem comparable
in this respect to aconite. My own experience is quite corroborative
of Dr. Clendinning's that it has a decidedly sedative effect in the
cough of bronchitis and phthisis. Dr. Tilt says it is a wonderfully
useful drug to quell neuralgia or mental excitement. In hysterical
derangement. Dr. Forbes Winslow finds that the tincture will occa-
sionally allay the excitement and produce sleep more rapidly than
any other form of sedative. Fronmuller finds that it produces a
more natural sleep than any other narcotic, and that its action is not
attended with any unfavourable after-effects. Sir R. Martin finds
it very effectually to arrest the vomiting of hysterical females, and
my own observation leads me to the same conclusion. Dr. Reynolds'
experience of it is peculiar; he says* it is useless in mere functional,
psychical, sensory, or motor disorders, without demonstrable organic
change ; on the other hand, it is essentially beneficial in cases of con-
gestion, softening, meningitis, or hemorrhage. The drug appears to
diminish the over-activity of the nerve centres without disturbing
the animal or vegetative functions. On the vaso-motor nerves I have
not observed it to have any action, but Dr. Churchill speaks of it as

1 "Arch, of Med.," Jan. 1861.

REMEDIES. 331

a valuable remedy in menorrhagia, classing it along with ergot of
rye. The general result seems to be that it is principally a cerebral
sedative, wbich is not appropriate to conditions of sthenic excitement,
but rather to such as manifest debility and depression with hyper-
sesthesia. Dr. Forbes Winslow gives a hint which is worth remem-
bering with regard to the employment of sedatives generally. This
is that cases which are intractable to separate remedies, Avill yield
to a judicious combination of several. This is probably the secret
of the success of the nostrum, chlorodyne.

Hydrocyanic acid is familiar to us all as a useful sedative in
gastric and bronchial irritation. It is evidently a nervine, but its
modus operandi is not at all clear. In poisonous doses it produces
tetanic convulsions and insensibility preceded by faintness and gid-
diness ; the pupils are dilated, the pulse is small or imperceptible.
In a good-sized young dog whom I injected with two t^^xxx doses of
acid, hydroc. dil. subcutaneously at about ten minutes' interval the
effects were as follows. He was prostrated in a few minutes, lay
quiet with deep but infrequent breathing, and quick but feeble pulsa-
tion of the heart, whose sounds were just audible. After the second
injection the breathing became slower, and the heart's action feebler,
and so he died very gradually in about twenty minutes from the first
introduction of the poison. A stimulus to the cornea caused con-
^ traction of the orbicularis palpebrarum from seven to ten minutes
before death, but not about four minutes later. At the autopsy
made two hours after death the limbs were not rigid, the lungs were
moderately congested, the heart was well and firmly contracted, its
tissue remarkably firm, the cavity of the left ventricle almost quite
obliterated, that of right small, but little blood in either, coagula in
both auricles. Brain decidedly pale. From this it almost appears
as if the heart's action had been arrested by over-stimulus of its
nerves, tetanizing it. Perhaps convulsions and insensibility are pro-
duced by similar tetanizing of the cerebral arteries. Such, however,
are the effects of over-doses, and they do not throw any light on the
results of ordinary ones. I believe we must for the present be con-
tent to think of the drug as a direct sedative to nervous tissue. As
such it has been used lately with great success by Dr. K. McLeod
in cases of insanity attended with excitement.

There is some evidence that the inhalation of Oxygen gas diluted,
in the proportion of from 2 to 12 per cent, for small doses, and to a
very much less degree for large doses, has a beneficial effect in various
disorders, among which some neuroses may be reckoned. One of
my own patients declares that he was restored by this means from
a state of extreme depression in a marvellous way. Dr. Birch, ^ who
has had the principal share in bringing this remedy forward, does
not recommended it in nervous hypersesthesia, or chronic cases of
extreme debility and spanaemia. He has found its good effects most

' "Brit. Med. J.," Dec. 24, 31, 1859.

332 REMEDIES.

decided " in persons of a gouty or strumous habit, or otherwise in a
state of general malaise^ with shiggish circuhition, either constitu-
tional or superinduced by an atonic and oppressed condition through
over-feeding and other luxurious habits." In some cases improvement
coincides with critical discharges of retained excrementitious mat-
ters. Mr. Hooper' records an intractable case of neuralgia of the
sole of the right foot which was cured after much other medication
had failed by the inhalation of oxygen. The patient was a labourer,
set. 40, the whole foot was exceedingly hot, the agony beyond de-
scription. No mention is made of gouty tendency. During the in-
halation the urine became increased in quantity, and loaded with
urates and phosphates. It seems probable that the remedy may be
useful in cases rather of indirect than of direct depression.

The operation of Oold on an ordinarily vigorous system is, as we
have seen, tonic and invigorating, v. p. 31 et seq. It increases ner-
vous power and specially excites the smooth muscular fibres of
arteries and of the skin, as well as the nerves influencing them.
Catarrhal affections are much more prone to ensue on the super-
vention of a thaw than during a sharp frost. In its greater degrees,
and in feeble states of system it is often depressing, partly we may
believe by obstructing the free flow of blood through the arteries.
The suppression of the catamenial discharge by the application of
cold to the feet, of hgemoptysis by ice to the chest, and the bene-
ficial eff'ect in cases of cerebral hypersemia of cold to the scalp in- *
dicate I think plainly that cold acts through the incident nerves in
a reflex manner upon the vaso-motor, and causes arterial contraction.
We shall see presently that heat has just the opposite effect. It
seems to me very probable that the extreme drow^siness which is pro-
duced by intense cold depends on a want of a due supply of arterial
blood to the brain, the congestion which is so often observed is pro-
bably chiefly venous, and dependent on the mode of death, viz., by
coma. The paralyzing action of cold in certain states of nervous
power has been already alluded to, v. p. 188, and forms a good ex-
ample of inhibitory action. It may aff'ect musculo motor or vaso-
motor nerves, and in the latter case may if the vital power is weak
originate actual inflammation by the hyperemia produced. The
toning anti-neuralgic influence of dry cold is well shown in the fol-
lowing case.

No. 185. — W. L., 8et. 32, a healthy man. Rather more than 2^ years
ago was struck by some small shot on the head, and has suifered ever since
with pains continually flying about the part, not felt anywhere else. The
head felt stiff, and tender, and heavy, and dull ; he could not find a comfort-
able position to lay it in. During the cold frosty weather the head was a
great deal better, and it was much relieved by pumping cold water upon it.
Health quite good all the time. The shots were removed by operation, were
flattened and imbedded a little in the bone. After their removal the pain
ceased. It is very noteworthy that a neuralgia of organic origin was thus

1 "Brit. Med. J.," March 15, 1862.

REMEDIES. 333

relieved by cold. Trousseau states that tetanoid spasms are temporarily
stilled iu the same way.

The action of moist ivarmth, whether applied by warm baths or in
any other way, is worth considering. It may be stated (1) that it is
generally soothing and comfortirrg to sensory nerves in a state of neu-
ralgic suffering, as for instance in the headache of influenza, and in
the case of tic douloureux recorded at page 185, but not so constantly
in the pain of inflammatory congestion, which, as in the case of a
burn, is often arrested by cold. However, there is good evidence
that in these same affections, even when very severe, moist warmth
may be one of the best means that can be employed. Mr. Windsor'
says, " Many years since we convinced ourselves by a series of com-
parative experiments that there was no treatment for the collapse
Avliich generally accompanies severe burns so eflScacious as th^ warm
bath. In our cases the pain at once disappeared, and sometimes
did not return, the pulse improved, and the countenance lost its
anxious and sunken case ; the bath, however, was never continued
for more than an hour." He thinks this treatment would often save
life. Hebra relates a case of severe burn, the subject of which nine
days after its occurrence was suffering intense pain, and could neither
stand, sit, nor lie down straight. She was placed in a bath at 99.5° F.,
and an hour later she could stretch her legs, and the pain had dis-
appeared. In forty-eight hours the pulse fell from 120 to 80, the
thirst became less and the appetite increased. She remained alto-
gether 604 hours in the water, the temperature of which was grad-
ually lowered to 88° F., and recovered well. The beneficial action
of cold in inflammation depends on its keeping the arteries con-
tracted, and the part aneemic, if it does not efi'ect this it is rather
irritating. (2) Moist warmth seems to abate the tissue irritation,
the attractive 7iisics, which constitutes the essence of sthenic inflam-
mation, causing afflux to and arrest of blood in the part independent
of arterial dilatation. In a case of very aggravated psoriasis under
my care the skin was paler after an hour's packing in a wet sheet
than at any other time. The beneficial eifect of poultices and
fomentations on inflamed parts, including the viscera of serous cavi-
ties, depends chiefly on this sedative action on the tissue, which ex-
tends even to the deeper parts. (3) I think we may be pretty sure
that moist warmth applied to the cutaneous surface through its
action on the afferent nerves and nervous centres relaxes the nerves
and vessels of internal parts. A female, whose catamenia returned
too frequently, informed me that soaking her feet in hot water would
bring on the discharge at any time. The common prescription of a
warm hip bath in amenorrhoea probably acts on the same principle,
as otherwise it would be more likely to determine a flow of blood to
the cutaneous surface than to the uterus. The benefit of a warm
bath in children's convulsions probably depends on its inducing re-

1 " Syd. Soc. Y.-b.," 1£63, p. 205.

334 REMEDIES.

laxation of the contracted cei'ebral arteries, and allowing free blood-
flow to take place through the brain. It should, therefore, not be
administered indiscriminately, not if the head was flushed and hot,
and the eyes injected.

Beneke^ and Clemens^ agree that the general eS"ects of baths de-
pend upon their action on the nerves of the skin. The latter finds
that simple or medicated baths always produce their greatest diuretic
eifect in the first fifteen or twenty minutes; he could detect none of
the substances dissolved in the bath water in the urine. The diu-
retic eff"ect was marked, especially in increasing the flow of water,
and the excretion of phosphates and other fixed salts. The chloride
of sodium and urea were not much increased. Beneke lays stress
on the importance of the stimulus of the bath being appropriate to
the state of the system ; if it is, it causes a general sensation of well-
being, a bodily and mental exhilaration, some increased frequency
of pulse, and generally and as an ultimate result an increase of
nutrition, and of the weight of the body. If, however, the stimulus
is not suitable to the individual, these beneficial effects are replaced
by shivering, lassitude, febricitation, restlessness, and loss of weight.

The special advantage of the warm bath consists in the circum-
stance that a very large sensory surface is mildly and equably stim-
ulated, so that all the cerebral and spinal centres are moderately
excited. It is on this principle that such baths as those of Gastein
and Wildbad, scarcely more than hot water, act efficiently in cases
of paralysis of exhaustion. This is the primary and beneficial effect,
but if the temperature be too high, or the bathing too prolonged, we
then have debility and nerve exhaustion produced, which may even
cause a degree of syncope, such as is not uncommon to novices at a
Turkish bath. The same influence which relaxes the internal
arteries, and thus promotes more free circulation through the brain
and cord, if carried too far, or used in too weakly a system, depresses
the action of the heart, sometimes even seriously.

Similar views seem to me very applicable to various medicated
baths of ascertained efficacy in different neuroses. Thus sulphuret
of potassium baths are certainly useful in chorea, in lead paralysis,
in some cases of asthma, and in some of eczema. It is difficult to
believe that the remdy can act by removing the causes of these dis-
orders, while it is certain that it must exert an influence on the
cutaneous nerves, which, communicated to the centres, may there
effect changes which materially modify the morbid phenomena. In
the following instance mentioned to me by Dr. Tyler Smith the
nitro-muriatic acid lotion appears to act in a way which can only be
explained by the view that certain nerves of the parietes exert an
influence on those of the contained viscera. A lady whose liver is
habitually torpid always gets a well-coloured bilious motion from the

1 Schmidt's " Jahrb.," vol. cxv. p. 101.

2 "iMed. Centr. Ztg.," xxx 53, 59^ 1861.

REMEDIES. 335

application of spongio-piline, saturated with nitro-muriatic acid lotion,
to the right hypochondrium, but a foot-bath of the same has no
effect.

In appropriate cases, such as are not suffering under active dis-
ease, there is no calmative which is more effectual than an atmos-
phere and climate suited to the state of the system. In asthma, in
chronic sleeplessness, and in a variety of obscure nervous disorders
change to a pure and suitable air may be of far more value to the
sufferer than any drug, or mode of treatment. This is eminently
the case in removal from London to the country. The cessation of
the unending hum and clatter of London traffic, the perceptible
stillness, affects the brain with a pleasant sense of rest, and con-
tributes materially to the beneficial effect of the air. A judicious
selection of locality is, however, most important. The atmosphere
■which tones, braces, and calms one system will injuriously affecj?
another, and the moist relaxing air of our southern and western
coasts which may calm a highly excitable, tensely nerved system
will seriously depress one of an opposite quality. For many invalids
convalescent, or semi-convalescent from tropical disease the Scottish
moors and mountains is, I believe, preferable to any in our island.
Were I similarly affected I should wish to betake myself to the Swiss
Alps, avoiding, however, absolutely the close valleys, which are often
most pernicious. I would say to every traveller in search of health,
consider well where you make even a brief stay, for a night or two
in a locality where the aspect of the population tells of malaria may
infect you with a taint which it may be hard to shake off, even if no
worse occur. I shall not as long as I live forget the scene that I wit-
nessed at Martigny during the day I halted there. A week of illness
spent there, commencing apparently in a mere diarrhoea, bereft a
young affectionate wife of her husband, and left her to finish in grief
the journey which had begun so joyously. In some cases frequent
change is more efficacious than a continued residence in any one
locality. This applies very much to the slight teasing febrile affec-
tions which hang about some who have previously suffered with
malarious fevers. For those who are tolerable sailors sea voyaging
under favourable circumstances is one of the best restoratives. To
many Indian invalids the long sea voyage would I am satisfied be
safer and more health-promoting than the over-land route.

APPENDIX.

The subject of inhibitory paralysis appears to me to be one of so much
importance that I am desirous of entering]; into it somewhat further than I
have done in the text. The following are, I think, interesting examples of
this morbid state. Mr. Tyrrell relates the following history.* "I was
requested to see a young gentleman, set. 13, who had been suffering for
many days from headache of severe kind, giddiness, flushed state of counte-
nance, and great restlessness and irritability; he was also intolerant of light,
and his vision was very imperfect, being obscured by a gauze or web. I
found the pulse rapid, small, but very compressible; the skin dry and hot;
and the tongue loaded on the median part by a thick light brown deposit,
the edges being unusually red ; the appearance of this organ induced me to
direct my inquiries into the state of the secretions from the alimentary canal,
and to examine the abdomen ; I then learnt that the patient had been freely
purged, principally by saline medicines ; but that the remedies had been
dii'ected to the head, under the supposition that it was the seat of the mor-
bid action ; my examination of the abdomen discovered an irregular, indu-
rated swelling in the right iliac region, which I considered to result from a
collection of hardened feces in the caput coli. A full dose of scammony
and calomel was administered and produced a very copious discharge of hard
scybala ; the relief was immediate; all urgent symptoms subsided, and after
a second dose he became convalescent — proving that all disturbance, cerebral,
ocular, or other emanated from the accumulation of scybala in the colon."
Tyrrell adds that such cases are rare in adults, but frequent in children or
young persons. Mackenzie^ relates the case of a girl, set. 7, whose vision
became dim after an attack of inflammation of the eyes attended with head-
ache, when suddenly her pupils became widely dilated and immovable. The
abdomen was much swollen. About a month previously to this she had
passed a lumbricus. After repeated doses of castor oil and turpentine she
passed at diff"erent times nine lumbrici, and vomited two; after which the
belly became soft, the pupils contracted when the eyes were exposed to the
light, and in the course of a few months' treatment vision was restored. Dr.
Burgess^ gives the history of a coloured man, set. 39, who suddenly began
to sufl'er severe pain through the right eye, and over the right side of the
face and head, and about this time discovered that he had paralysis of the
right side of the face. The pain continuing most severe through the globe
of the right eye he soon began to experience a cloudiness of vision. For
the first few days all objects viewed with the right eye alone seemed of a
bright yellow colour ; at the end of five or six weeks the power of vision was
entirely obscured. Now began a similar set of symptoms in the left eye,
resulting finally in total loss of sight in this eye also. This condition was

' Vol. ii. p 280.

2 ''On Dis. of the Eyes," p. 1061.

« "Brit. Med J.," June 14tli, 1862.

23

338 APPENDIX.

reached in about four months after the first attack. Two months later the
eyes had a staring vacant aspect, the globes being prominent, as if pushed for-
wards, the pupils largely dilated, and but little sensitive to light. No evi-
dences of disease in the external coats of the eye; the deeper portions "pre-
sented a greenish colour. Paralysis of the muscles of the right side of the
face v?ith partial paralysis of the tongue still existed; and pain similar in
character, though much less severe than that which had ushered in the dis-
ease, still continued. He also described a sensation as of something crawl-
ing about on the top of his brain. He had chancre four years before, but
had never suffered from any consecutive symptoms. Shortly after this he
was delivered from a taenia nineteen feet long by means of pumpkin-seeds
and castor oil and turpentine. Two or three days after this he began to
distinguish shadowy outlines of objects around him, and from this time the
haze cleared away so rapidly that in a week more he was able to recognize
his acquaintances. At this time the power of vision was returning only to
the right eye, but soon after the left improved also. At the end of thirty
days the patient could read newspapers, the pain had nearly disappeared, and
both eyes had a perfectly normal appearance, save the glaucomatous hue of
the inner chambers, which still existed. Paralysis continued, but was less
evident. Two years and a half later the patient's sight still remained unim-
paired, or nearly so, and the paralytic effects had all disappeared.

Remarks. — In the first of these cases there were signs of cerebral con-
gestion, of retinitis, and general pyrexia ; in the second, there was headache^
paralysis of the ciliary nerves, and ophthalmia; in the third, pain in the
head and face, paralysis of the facial and hypoglossal nerves, and retinitis lead-
ing to amaurosis. In all the phenomena were evidently dependent on remote
irritation. The natural reading of the phenomena seems to me to be — in the
first, paralysis of the vaso-motor nerves of the retinal, facial, and cerebral
arteries ; in the second, cerebral neuralgia, and inhibitory palsy of the ciliary
branches furnished by the third pair and of the vaso-motor nerves of the
eyes; in the third, similar but more extensive neuralgia and palsy, the latter
involving also both retinal vaso-motor nerves. If any one should contend
that the condition in the first case was not one of vaso-motor nerve paralysis,
but of direct cerebral and retinal irritation, which I can hardly think is
possible, this will not apply to the second case where there was paralysis of
ciliary nerves along with the ophthalmia, and still le,ss to the third where
there was palsy of the right facial and hypoglossal together with retinitis.
If the retinae were directly irritated the origins of these nerves should have
been so too, and there should have occurred contraction rather than paralysis.
In the cases quoted from Scanzoni, at p. 462, it seems impossible to believe
that the cutaneous hyperaemia was the result of attraction of blood to the
skin excited by reflex irritation. It would be as reasonable to regard blush-
ing as the result of cutaneous irritation. Tissue irritation, as when produced
by a mustard poultice, is always attended with more permanent phenomena
than those resulting from arterial dilatation. The diffuse character of the
inhibitory vaso-motor paralysis is very apparent in the first case, and it is
worth observing that both eyes were affected in all the three. If spasm of
the vessels in the centres had been the cause of the palsy in the third case,
should not the retinal vessels have been in a similar condition, and would
not, moreover, the long period during which the nutrition of the centres
was arrested have produced softening and irreparable damage ? Dr. Brown-
Sequard asserts that an inflammation cannot be explained by a hypersemia

APPENDIX. 339

c

rom vaso-motor nerve paralysis, but, as I have before stated, my own ex-
perience quite coincides with Bernard's, that in weakly or sickly animals
actual inflammation may be produced by division of the sympathetic. This
conclusion seems to me quite borne out by the evidence of the above cases.
No. 55 may also be cited as a proof that long-continued hyperaemia from
relaxed arteries may pass into destructive pus-generating inflammation.

While, however, I think that inhibitory paralysis of musculo-motor, and
of vaso-motor nerves is not an infrequent form of disorder, and that the
latter often gives rise to inflammation of a more or less diffuse kind, I also
think there is evidence that nerve pain or nerve palsy may cause nutritional
changes of inflammatory character. Herpes Zoster is an oft-quoted instance.
Graves relates a case (Dublin Med. J., vol. iii. p. 342) where a gentleman,
aet. 68, had an attack of hemicrania affecting the right side. Each hair felt
like a minute poniard implanted in the skin, causing intense agony; at last a
minute pustule that soon desiccated appeared around each hair, and in a few
days his scalp got well. During the height of the disease the engaged half
of the scalp was red, but not erysipelatous. The hair did not fall off.
Samuel's experiments, if confirmed, prove that severe irritation of sensory
and compound nerves may cause violent inflammation. He states^ that irri-
tation of the tissue in the vicinity of the sciatic nerve produced healthy
suppuration along the course of the nerye and its divisions, but did not ex-
tend to the lower part of the leg and foot. The skin and the muscles were
not inflamed. Prolonged irritation of the sciatic nerve on the contrary
caused prodigious swelling and inflammation of the whole limb, with offensive
sanious exudation and discoloration of the muscles. Irritation of the pos-
terior spinal nerve roots and their ganglia in the lumbar region caused great
swelling and hypersemia of the leg and thigh. It does not appear to me
quite certain whether in these experiments the irritation was not so great as
to paralyze the vaso-motor nerves, at the same time that by its action on
the sensory it impaired the nutrition of the tissues. Hutchinson's cases
show that small whitlows may form on the fingers in consequence of their
being deprived of sensation. As counter-evidence to Samuel's experiments
we ought to consider the numerous instances in which severe pain is pro-
duced either by direct or reflected irritation of sensory nerves, yet without
any inflammation ensuing in the part to which the pain is referred. Such
instances are so numerous that it is needless to cite any at length, and I
■will only allude to two cases mentioned by Sir B. Brodie {Local Nervous
Disorders, pp. 4, 5), to three cases mentioned by Romberg (vol. i. p. 72, 7o),
and to an interesting case given by Dr. Churchill (Dis. of Women, p. 25.3)
in which uterine cancer gave rise to no other pain except excruciating
sciatica. In none of these was the nerve irritation attended with any inflam-
mation. Neither was it in Denmark's'^ case where a fragment of lead im-
pacted in the radial nerve caused such suffering in the hand that amputation
was had recourse to, nor in a case given by Sir Charles Bell,^ where a "man
died of agonizing burning pain in the sole of his foot, and the poisonous
drugs that were administered in hope of relieving him. Only two days
before his death I found a hard tumour like a piece of bone in the ham, and
that the pain in the foot proceeded from this." After death the popliteal

' Canst. " Jahresb.," vol. ii. pp. 53-57.

2 Med.-Chir. Trans., vol. iv. p. 48. It is true that there was an excoriation in the
palm, but the skin here is supplied by the median nerve.

3 "Nervous System," 1836, p 370.

340 APPENDIX.

nerve was found involved in a soft cancerous mass. In most cases vrhere
neuralgic pain is attended with some degree of inflammation this evidently
depends on vaso-motor paralysis and not on tissue irritation. This appears
from the diffuse hypersemia, the throbbing, the paroxysmal aggravation, and
especially from the cure of the whole disorder by tonics. Brodie especially
mentions that inflammation produced by nerve irritation is not very active,
is not such as will end in suppuration, or abscess. In Mr. Paget's case
where urethral irritation caused abscess in one testis we need more exact in-
formation respecting the state of things during the time that the abscess was
forming. It does not seem to me fully proved that the morbid action was
not communicated by continuity of tissue. This is the explanation which
Dr. Mackenzie is most inclined to adopt with regard to sympathetic ophthal-
mitis. He says : " It is extremely probable that the retina of the injured
eye is in a state of inflammation, which is propagated along the correspond-
ing optic nerve to the chiasma, and that thence the irritation which gives
rise to inflammation is reflected to the retina of the opposite eye along its
optic nej:"ve." If the view be taken that the inflammation depends on in-
hibitory irritation of the nerves of the secondarily-affected eye, it should be
observed that, as Dr. M. states, the subjects of sympathetic ophthalmitis are
debilitated and in ill-health, and that the inflammation is unhealthy. The
occurrence of purulent otorrhcea together with auriculo-temporal neuralgia
is clearly an instance of vaso-motor nerve paralysis, the vasal nerves being
paralytically affected like the sensory.

On the whole, after comparing the teachings of science with our expe-
riences in practiccj I find that the theories of vaso-motor paralysis, of in-
hibitory action, and of the paralytic character of neuralgia are of great value
as affording a rational basis for treatment, and as combining together in an
intelligible view numerous facts which would otherwise be of little signifi-
cance ; — but the doctrine of special trophic nerves seems to me at present
to be but sparingly applicable to the phenomena of disease. One of its
principal supporters (Samuel) regards fever and inflammation as states of
excitement of the trophic nerves, and atrophies as the reverse. Now certainly
the view which Bernard's observations lead to as regards fever and many
cases of inflammation is much more consonant with experience.

The essential idea of the inhibitory theory is that a peculiar kind of im-
pression made on a centre may disorder or paralyze its action, may prove
directly depressing. There seems to be ground for believing that such im-
pressions may be generated within the cranial cavity as well as at the pe-
riphery. The crossed paralysis resulting from hemorrhage into one hemis-
phere of the cerebellum seems only explicable on the view originally pro-
pounded by Mayo that the fibres of the transverse commissure coming from
the diseased side communicate "a depressing" or "withering influence" to
the descending fibres conducting voluntary motor impulses. Perhaps it may
be more correct to regard all the fibres uniting together nervous centres as
wholly commissural, and to consider the morbid influence in this case there-
fore as affecting the gray matter of the pons Varolii rather than the fibres,
but this is only a slight modification of the original view. One circum-
stance which seems to support it is that the crossed paralysis only occurs,
according to Hillairet,* in about one-third of all the cases ; — the reason
being, that in the other two-thirds the morbid impression is either ihsuflicient

* "Ann. de Med. et de Chir. pratiq. par Jamain," 1859, p. 39.

APPENDIX. 341

to overcome the volitional impulse, or takes another direction, as to the
corpora quadrigemina, causing blindness or convulsions, or to the medulla
oblongata impairing respiration or speech, or even to the lower part of the
cord producing predominating paraplegia. The non-occurrence of para-
lysis in some cases of disease of the cerebrum itself is probably to be ex-
plained in the same way. It is not the lesion of the hemisphere per se that
causes the paralysis, but the depressing influence of this lesion on the deeper-
seated cerebral ganglia. Paralysis therefore may or may not exist according
to the quality of the nervous power, or the peculiar kind of lesion. In cer-
tain instances, as Dr. Ogle^ has pointed out, the morbid influence may take
another route and act on the cerebral ganglia of the opposite side so that the
paralysis affects the limbs on the same side as the lesion. This view may
afford some rational ground for treatment in cases which would otherwise
be hopeless. It is true that we may be unable to amend materially the
state of the damaged part, but we jnay be able so to improve the functional
power of a connected centre that it shall not be depressed by the " withering
influence" conveyed to it from the seat of the lesion.

' ^'Med.-Chir. Trans.," vol. 42.

YINDEMIATIO.

(1.) In all cases we should be guided as to treatment by the pathological
condition existing much more than by the name of a disease. Morbid con-
ditions called by the same name may be utterly different essentially, and '
require most different management. We should always endeavour to esti-
mate the quality and amount of the nervous power.

(2.) The same cause may give rise to very various and even apparently
opposite effects, according to the state of the nerve or nervous centre on
which it acts ; thus an irritation may either paralyze a muscle, or throw it
into convulsion or into rigid spasm ; may cause pain or numbness or local
tenderness; may produce cerebral excitement or depression. Much depends
on the degree of irritation, a moderate may excite, while a powerful may
depress. The same may be said of the kind or quality of the irritation, an
appropriate kind stimulates, while one which disagrees has an opposite effect.

(3.) The result of a stimulant or of a sedative may be different according
as it affects the cerebro-spinal or vaso-motor nerves. The constriction of the
arteries produced by the action of a stimulant on the latter may diminish or
temporarily arrest functional power, and vice verm dilatation of arteries
produced by a sedative may give rise to excessive action. The operation of
these agents on the cerebro-spinal nerves or centres is just the reverse.

(4.) Hyperaemia from paralysis of vaso-motor nerves is very common, and
may under conditions of general exhaustion or local irritation pass on into
actual and complete inflammation. This hyperaemia or inflammation is
always diffuse.

(5.) We should bear in mind the frequent occurrence of reflex inhibitory
action, implying the paralysis of cerebro-spinal or sympathetic nerves, as
the result of a stimulus morbid in kind or degree in relation to the centre
on which it acts. Such morbid impressions may originate within the cranium
from lesion of the membranes or of a nervous centre.

(6.) Debility and excitability of nervous centres and nerves very often
increase pari passu, but the former may exist alone. When very great it
constitutes what may be termed simple paralysis, a simple loss of functional
power. This is specially distinguished from reflex paralysis by being
amenable to repose, generous diet and tonics, while reflex requires the re-
moval of the exciting cause. Simple paralysis of a nervous centre much
more often affects motion than sensation. It occurs both in the spinal and
encephalic districts,

(7.) Paresis of nervous centres constitutes the primary and essential part
of the affection termed sunstroke or heat-apoplexy ; the vascular congestions
being induced secondarily and depending in great measure on loss of tone iu
the capillaries and small arteries. According to this view the intimate rela-

344 VINDEMIATIO.

tion between such disorders and various forms of fever is easily intelligible,
as vaso-motor paresis seems to constitute an essential part of all febrile
movement.

(8.) Active cerebral excitement may be either of a sthenic, an asthenic, or
a medium quality, and will require corresponding modifications of treatment,
and this independently of the nature of its exciting cause. This entirely
applies to delirium tremens.

(9.) Spinal excitement (tetanus) is to be regarded more as a dynamic
than a toxic affection. Its affinity to paralysis, and its relation to prostrating
influences, as prolonged heat and cold and wet, should be borne in mind.
Catalepsy, a variety of tetanus, is sometimes produced by exhaustion.

(10.) The epileptic paroxysm is immediately dependent on spasm of all
the encephalic arteries in the greater, and those of the hemispheres only in
the minor form. Sudden temporary aDseraia is thus the necessary condition
of the occasional paroxysm, but in prolonged convulsions, as puerperal, ex-
an thematic, of tubercular or of uraemic origin, it is probable there is direct
irritation of the tubercular quadi'igemina and adjacent parts with more or
less secondary hypergemia. The latter when primary may no doubt be a
predisposing, but if it stop short of actual inflammation, is scarcely ever an
exciting cause of convulsions. Hyperaesthesia of the excitable districts,
quite analogous to that affecting peripheral nerves, is, however it may be
excited, the fundamental cause of convulsions. According to the quality of
this hypersesthesia counter-irritants, sedatives, or tonics, or a combination of.
them may be requisite.

(11.) Chorea is in most cases a dynamic disorder of debility, involving a
greater or less extent of the cerebro-spinal centres, sometimes only the motor
apparatus, sometimes the hemispheres also. Paralysis agitans, when not of
organic origin, is a similar but more limited affection involving some part of
the spinal centres.

(12.) Muscular spasms and contractions are attributable to disorder of
motor nerves similar to the neuralgia of seiisory, and like them are some-
times of central sometimes of peripheral origin. They may also be of sthenic
or asthenic quality. A series of gradations may be traced from tonic spasms,
through clonic tremors, and choreic agitation to actual paralysis.

(13.) Wherever nerves exist neuralgic affections may and do occur. As
to their quality they may present either that of hypersesthesia where ten-
derness and excitement predominate and sedatives relieve, or that of neu-
ralgia characterized by pain and depression, and relieved by stimulants.
These are the typical forms, but of course intermediate and mixed ones are
most common. As to their origin they are in most cases intimately con-
nected with depressing agencies, or with malaria, but may be dependent on
remote irritation, or gouty or syphilitic poison.

(14.) Headache may be produced either by neuralgic affection of the
brain itself, or of the nerves of the parietes, and may be characterized by
hyperaesthesia, or by prostration. Like other nerve disorders it may be
produced by direct or remote irritation.

(15.) Vertigo may be produced by any sudden alteration in the state of

VINDEMIATIO. 345

the cerebral circulation, or by enfeeblement of its power, or by direct or
remote irritation interfering with the due action of its tissue.

(16.) Angina pectoris is essentially a cardiac neuralgia, consisting as so
often observed in other situations of sensory and motor disorder, pain and
spasm. It may be produced by very different causes as well as other cardiac
neuroses.

(17.) The fatal termination of laryngismus stridulus probably depends
on cardiac spasm associated with the glottic.

(18.) The convulsions attending on pertussis and other severe coughs do
not depend on hyperfemia of the brain, but on propagation of the motor dis-
order to the nerves of the cerebral vessels.

(19.) Hemorrhages to a greater or less amount may result from causes
of prostration acting through the vaso- motor nerves on the small arteries
and capillaries. The nerve paresis causing dilatation of the arteries flushes
the parts which they supply with blood, while the same condition impairing
the quality of the capillary wall allows actual blood to escape into the tissue
or on a free surface.

(20.) Miasmata giving rise to ague are generated occasionally in and
around London. Young children are prone to sufier from a remittent fever
of this kind attended with various complications. In adults it sometimes
shows itself in a very obscure form attended with great nervous prostration
and depression.

(21.) In well-marked cases of hysterical disorder (so called) the mind
and morale may be perfectly sound and healthy.

(22.) Remember the distinction between the radical and the acting forces,
V. p. 216.

(23.) In treatment large allowance must be made for idiosyncrasy; the
kind of remedy may be clearly enough indicated, but it may not be easy
to determine the particular one required. It is also essential to ascertain
the proper dose; a remedy may fail because given in too large or too small
an amount, or because it has not been given for a- sufficient length of time.

II^DEX.

Abdominal neuralgia, cases of, 429
Acids, sulphuric and nitric, action of, 322
Aconite, uses of, 330
Ague, greater prevalence of, 18
Ansemia, cerebral, 48

spinal, 61
Ansesthesia, cutaneous, 278

retinal, 193
Angina-pectoris, 210
♦ Anodynia, cutaneous, 279
Arsenic, action of, 316
Arteritis, results of, 42
Asthma, 239

Pridham's treatment of, 242

Ducros' medication in, 244
Atropine in cough, 234
Aura epileptic, 137, 142
Azoturia, 263

Baruria, 263

Uatb, shower, 33, 34

warm, action of, 334

in syncopal ague, 226
continuous in burns, 69
in sleeplessness, 179

Belladonna, action of, 327

Bladder, neuralgia of, 262

Bronchial hypereesthesia, cases of, 231, 232

Burns, results of, 69

Cannabis indica, action of, 330
Capillaries, atony of, from sunstroke, 267
Cardiac neuroses, rheumatic, 218

malarious, 220

saturnine, 226

connected, with Goitre Exoph-
thalmia, 227
Cardiac hyperassthesia, 229
Catalepsy, 131
Chloroform in tetanus, 129
Chorea, 160

Colchicum, in delirium, 106
Cold, effect of, 31, 32, 332
Compressed air baths in asthma, 243
Convulsions, puerperal, 148
Cramp, Writer's, 173
Cutaneous hypersesthesia, 275
ansesthesia, 278

Cutaneous —

analgesia, 278

hemorrhage neuropathic, 282
Cutaneous arteries, spasms of, 282

%
Delirium, sthenic, 101

asthenic, acute, 107

tremens, 112

in rheumatic fever, 103
Digitalis, action of, 319
Drowsiness, 179

Ear, cauterization of in sciatica, 209
Epilepsy, 134

cases of, 144

treatment of, 140
Excitement, cerebral, 100

spinal, 123
Exercise, effect of, 30

Fever, neuropathology of, 34
malarioid, 291

remittent obscure, 297
Flatulence, gastric, 215

Habit of action, 168

Hgemorrhage, intestinal from nervous pa-
resis, 269, 270

gastric from nerve paresis, 258, 259
HEematemesis, from nervous paresis, 259
H03maturia,from nervous paresis, 266, 267
Headache, 153
Heat-apoplexy, 81

after symptoms of, 82
Hiccup, 246

Hydrocyanic acid, action of, 106, 331
Hypersemia, cerebral, 63

spinal, 71
Hyperassthesia

gastric, 255

uterine, 273

retinal, 190
Hysteria, 307

Incontinence of urine, diurnal, 266

nocturnal, 266

gouty, 262
Influenza, effects of, 85

848

INDEX.

Inhibitory theory, 22, 24, and appendix
Iris, action of opium on, 324
belladonna on, 328
Iron, action of, 318
Irritation unfelt, 21

Lactic acid, 253
Laryngismus stridulus, 235

T. Paget's remarks on, 238

Malaria, action of, 288
Malarioid disorder, 287
Malarious epilepsy, 139
Menorrhagia, treatment of, 274
Menstruation, state of vessels and nerves

in, 272
Monotony, ill effects of, 79
Myalgia, 248

Nerves, division of, in neuralgia, 187
Nervous influence, results of loss of, 284,

286
Neuralgia, relations of, 44

nature of, 39

seat of, 42

facial. 181

abdominal, 249

brachial, 197

sciatic, 204

lingual, 194

vesical, 262

rectal, 271

uterine, 272

epileptiform, 187

osteal, 286

crural, 209
Neuroses, cardiac, 217
Nicotine in tetanus, 130
Nocturnal aggravation of nerve disorder,
44

Opium, 328

action of, on iris, 324
Oppler on the function of the kidney, 263

Paralysis, facial, 188
agitans, 165
infantile, 92
diphtherial, 98

Paresis, cerebral, 74

spinal, 88
Pertussis, 233
Pfliiger's laws, 21
Pyrexia, 215

Quinine, action of, 315

Radcliffe's views, 45
Pi,adical forces, 216
Reaction, 33

PiBctum, neuralgia of, 271
Respiratory neuroses, 231
Rheumatic nerve affection, 312
Rigors in fever, 37

Sciatica, 204
Secretion fluxes, 306
Shower bath, efi"ect of, 33, 34
Sleeplessness, 174
Sneezing, 244
Soporose affections, 180
Spasmodic affections, 169
Strychnia, action of, 318
Sulphuret of potassium baths in chorea,
161
in asthma, 243
Syphilitic nerve affections, 310

Tannin, action of, 322

Tartar emetic, action of, 106, 114

Tea, action of, on heart, 217

Tetanilla, 128

Tetanus, 123

Throat dyssesthesia, 198

Tobacco, action of, on heart, 218

Trismus, 169

Urinary organs, neurosis of, 261
Urticaria, 276

Uterus, irritable, McKenzie on, 273
Uterine neuroses, 271

Vaso-motor nerve, functions of, 25 et seq.
Vertigo, 157

Warmth, moist, action of, 333

Yawning, 247

(Oct., 1885, 20,000)

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